If you’ve ever had a health insurance plan through an employer, you know that it may cover you for certain health services and not others. You may have to pay copayments or coinsurance, and you may buy supplemental insurance, like life insurance, to fill gaps in coverage.
Although all health plans help you pay for your medical services, there are some crucial differences. And understanding those differences is an important part of knowing which plan is right for you.
Take TriTerm Medical insurance, underwritten by Golden Rule Insurance Company, for example. It’s a type of short-term limited duration insurance that you can enroll in if you’re between plans or looking for an alternative to shopping on the federal marketplace or your state’s exchange for an Affordable Care Act (ACA) plan.
Below, find out how TriTerm Medical plans, underwritten by Golden Rule Insurance Company, differ from ACA plans.
ACA plans normally run from January 1 through December 31. You need to review them every year, but you can often keep the same plan as long as it’s still available. Generally, if you sign up after December 15, coverage won’t start until February 1 — but some states have slightly different rules, so it’s a good idea to familiarize yourself with them (you can also call a licensed insurance agent at 1-844-211-7730 for more information).
TriTerm Medical plans last for nearly 3 years, which is where the name “TriTerm” comes from. In most states, that means 3 years minus 1 day. (It varies in a few states; for example, in Oklahoma, plans have 3 364-day terms.) Even though the TriTerm coverage period lasts that long, it’s still considered short-term limited duration medical insurance.
With ACA plans, you must enroll in a plan during its annual Open Enrollment Period (OEP). That’s normally between November 1 and January 15, though a few states have slightly different enrollment periods.
Otherwise, the only way you can enroll at a different time of the year is if you qualify for a Special Enrollment Period (SEP). That’s when you have a significant life event, such as losing your workplace health plan or moving to a community with different health plan options.
It’s worth noting that you can enroll at any time if you earn less than 150% of the federal poverty level. For example, that’s $21,870 for an individual or $45,000 for a family of 4. You can also enroll at any time if you’re a Native American or Alaskan Native member of a federally recognized tribe.
With TriTerm Medical plans, on the other hand, you can apply for them any time you want to. And you aren’t limited to a January 1 start date. So, for instance, if your workplace health plan ends on September 30, you could start TriTerm Medical coverage on October 1.
A provider network is the group of doctors and health care facilities that have agreed to accept the health plan’s terms and prices. Possible network types for ACA plans include:
Generally, the more restrictive the network, the lower your monthly insurance bill (premium) may be.
TriTerm Medical plans, on the other hand, are all PPO plans, so you have access to UnitedHealthcare’s nationwide Choice Plus Network of 1.5 million providers and more than 7,000 medical facilities.
In some states, you can also choose to see someone who is not in network, but you’ll pay more. Specifically, you’ll pay all charges above what is considered an eligible expense plus a penalty of 25% of the eligible expense. Also, the non-network deductible is double the network deductible. (A deductible is what you pay for medical services before your insurance pays the rest.) So you’ll have to pay twice as much out of pocket before your expenses even qualify for coverage. In other states, no benefits are paid at all if you go out of network.
If you have an ACA plan, the government requires it to cover 10 essential health benefits, including things like:
The specifics of coverage varies by plan, so comparison shopping is important. Note that some preventive services — such as behavioral counseling and certain vaccines — may not be covered in the future. However, this could still change based on more court action.
TriTerm Medical plans, on the other hand, aren’t required to comply with ACA regulations. While there’s a lot of overlap in covered benefits, it’s important to review the medical benefits, exclusions and limitations listed in the TriTerm Medical brochure. These can vary based on your state, too.
ACA plans are called “guaranteed issue” plans. That’s because, by federal law, you can’t be turned down for coverage due to preexisting conditions. They’re also required to cover those preexisting conditions. This means if you already had a specific condition, such as diabetes or cancer, before your coverage started, the plan must cover care for that condition in the future.
With TriTerm Medical, your application goes through medical underwriting. That’s a process that involves a review of your medical history before it can be approved. These plans can deny you coverage based on the results of your medical underwriting, and preexisting conditions aren’t covered until you’ve been on a plan for 12 months. (Some states have different exclusion periods.)
Depending on your household income, you may qualify for premium tax credits to help lower what you pay monthly for your insurance when you buy an ACA plan. You may also qualify for cost-sharing reductions, including a lower deductible, lower out-of-pocket maximums, and lower copays and coinsurance.
You’ll want to be aware that TriTerm Medical plans are not eligible for any financial assistance. But if you don’t qualify for ACA premium tax credits and other cost-sharing reductions, a TriTerm Medical plan may be a better buy.
TriTerm short-term limited-duration coverage is not required to comply with certain federal market requirements for health insurance, principally those contained in the Affordable Care Act. Be sure to check your policy carefully to make sure you are aware of any exclusions or limitations regarding coverage of preexisting conditions or health benefits (such as hospitalization, emergency services, maternity care, preventive care, prescription drugs, and mental health and substance use disorder services). Your policy might also have lifetime and/or annual dollar limits on health benefits. If this coverage expires or you lose eligibility for this coverage, you might have to wait until an Open Enrollment Period to get other health insurance coverage.
Centers for Medicare & Medicaid Services. “Nearly 16 Million People Have Signed Up for Affordable Health Coverage in ACA Marketplaces Since Start of Open Enrollment Period,” January 11, 2023. Retrieved from https://www.cms.gov/newsroom/press-releases/nearly-16-million-people-have-signed-up-affordable-health-coverage-aca-marketplaces-start-open
Harvard Law School. “Three Reactions to Braidwood v. Becerra,” April 3, 2023. Retrieved from https://blog.petrieflom.law.harvard.edu/2023/04/03/three-reactions-to-braidwood-v-becerra/
HealthCare.gov. “Federal Poverty Level.” Retrieved from https://www.healthcare.gov/glossary/federal-poverty-level-fpl/ Accessed July 27, 2023
HealthCare.gov. “Health Insurance Plan & Network Types: HMOs, PPOs, and More.” Retrieved from https://www.healthcare.gov/choose-a-plan/plan-types/ Accessed July 27, 2023
HealthCare.gov. “What Marketplace Health Insurance Plans Cover.” Retrieved from https://www.healthcare.gov/coverage/what-marketplace-plans-cover/ Accessed July 27, 2023
UnitedHealthcare. “TriTerm Medical Plans.” (For states GA, KY, NC, OK, UT.) Retrieved from https://www.uhone.com/api/supplysystem/?FileName=45712P-G202012.pdf Accessed July 27, 2023
UnitedHealthcare. “TriTerm Medical Insurance.” Retrieved from https://www.uhone.com/health-insurance/triterm-medical-insurance Accessed July 27, 2023