*NOTE: This article describes the 2017 ACA open enrollment process. Please refer to www.healthcare.gov or your state’s marketplace website for 2018 open enrollment information.
My family and I have health insurance! This may seem like an obvious statement, but a few days ago, as 6/30/17 was quickly approaching, I began to panic. Why is 6/30/17 significant? It was my last day as a full-time employee, which meant it was my family’s last day of coverage through my employer-sponsored health insurance plan. I had spent a lot of time researching health plans but had not yet applied for coverage. My husband and I explored the option of purchasing a COBRA plan (read 10 Things You Need to Know about COBRA for more information), but after learning we would be stuck with very expensive health insurance until open enrollment season, we decided to purchase a plan through the insurance marketplace, also known as the health care exchange. Our experience was very positive. We spoke to a navigator to clarify details about the coverage, then we completed the online application in less than 15 minutes! Below, I share the information I learned during this journey.
The Patient Protection and Affordable Care Act, typically referred to as The Affordable Care Act, the ACA, or its nickname “Obamacare”, is a federal law designed to improve access to health care. The law mandated numerous changes to the health care system, most notably in the individual health insurance market. One of the provisions of the ACA was the creation of health exchanges. Also known as the Health Insurance Marketplace, the exchange is a service available in every state that helps individuals and small businesses purchase affordable private health insurance plans.
The entire process can be done online. Customer service representatives (also known as navigators) are available via telephone to answer questions and provide assistance. Alternatively, the application can be completed over the phone, you can apply in person, or you can mail a completed paper application.
Tip #1: You can only purchase health insurance on the exchange during the open enrollment period (see exceptions in Tip #2).
The open enrollment period for 2017 ended January 31, 2017. The open enrollment period for 2018 is November 1, 2017- December 15, 2017.
Tip #2: Outside of the open enrollment period, you can purchase health insurance IF you qualify for a special enrollment period.
The following life changes qualify individuals for the special enrollment period: 1) Losing job-based coverage, 2) Losing COBRA, 3) Losing coverage provided through a family member (through death, divorce, or events that cause the primary subscriber to lose his/her eligibility for coverage), 4) Losing eligibility for Medicaid or CHIP (Children’s Health Insurance Program), 5) Marriage, 6) Birth or adoption of a child, 7) Change in residence to a new zip code, 8) Moving to or from a shelter or transitional housing, 9) Leaving incarceration, 10) Becoming a U.S. citizen
Tip #3: There is important information you need to gather prior to beginning the application. Be sure you have the following:
- Name, date of birth, and social security numbers for each household member applying for insurance
- Employer and income information for each household member (from W2 or pay stubs)
- Tax returns for the previous 1-2 years
- Estimate of your household income for the current year
- Relevant documents for legal immigrants
Tip #4: Pay close attention to enrollment deadlines.
During open enrollment season, you must apply at least 15 days in advance to get coverage on the 1st day of the following month. If you qualify for the special enrollment period, you can apply up to 60 days prior and must apply within 60 days after the date of the qualifying event that caused you to lose insurance coverage. If you miss this window you will have to wait until the next open enrollment season.
Ready to purchase health insurance through the exchange? Follow these steps:
- Go to healthcare.gov
- You will be asked to select your state from a drop down list and will subsequently be directed to your state’s marketplace.
*Please note that each state’s marketplace is unique. The information I am sharing is based on my experience with my state of residence. Please be aware that your state’s application may have additional requirements. Be sure to follow the directions for your state.
- You must create an account with a username and password, which will allow you to resume the application if not completed and review your information in the future.
- A variety of plan types will be offered, which may include the following: HMO, PPO, POS, and HDHP. Read How to Choose the Health Insurance Plan That’s Best for You for more information regarding these plans.
- Browse and compare the health insurance plans offered by your state’s marketplace. This feature is very helpful and allows you to compare benefits, covered services, and costs (such as copays, deductibles, and monthly premiums).
*Note: The number of participating insurance companies varies in each state, ranging from as little as 1 in Alabama, Alaska, Oklahoma, South Carolina and Wyoming to as many as 15 in Wisconsin.
Plans offered through the health exchange are assigned “Metal Levels”. As you move up the metal levels, the monthly premium increases and the out-of-pocket costs decrease. Bronze plans cover 60% of expenses for an average consumer. Individuals who purchase bronze plans will generally have the lowest monthly premium but will have more out-of-pocket expenses when utilizing insurance benefits. Silver plans cover 70% of expenses, Gold plans cover 80%, and Platinum plans cover 90%.
- Enter the names of your current physicians (and those of your family members) to determine which of the available plans they participate with. This is extremely important if you have chronic health conditions and want to continue seeing your primary care provider and/or specialist(s).
- Enter the names of the medications you are taking (and those of your family members) to determine if they are covered by the available plans. Each plan has a formulary, which is a list of approved medications. Most plans assign a tier level to medications. Your out-of-pocket costs increase as you go up the tier, and medications not on the formulary will not be covered.
- To start the enrollment process you will be asked to enter the name, date of birth, and social security number for each household member you plan to include on the application.
- To determine if you or your family members qualify for Medicaid, CHIP, or a subsidy (a discount on the monthly premium), you will be asked to enter the estimated household income for the current year. If you qualify for assistance, you may also be asked to enter income information for 1-2 prior tax years. If you don’t qualify for savings, you can either proceed with purchasing health insurance through the marketplace or you can purchase directly from a private insurance company or through an agent or broker.
- After you complete the enrollment process, your coverage does not begin until you make your first premium payment. You will have a limited time to make the first payment before your policy will be canceled.
*Note: The payment is made directly to the insurance company, not through the exchange. If you do not hear from the carrier within a few days of enrollment, be sure to contact them directly.
- Pay monthly premiums by the deadline to avoid termination of coverage.
In summary, if you are ineligible for health insurance through an employer-sponsored plan or Medicare, you can purchase insurance through the health exchange. Visit www.healthcare.gov and proceed to the website for your state’s marketplace. If there is more than one plan offered, be sure to compare monthly premiums, out-of-pocket expenses, determine if your current physicians participate with the plans and if your current medications will be covered. Be mindful of the deadlines and contact the customer service representative for your state if you have questions. While it may sound a little overwhelming, the process is actually quite seamless and I am thankful to have had this option for myself and my family.
Have you joined the Your GPS Doc Family? If not, please click here to receive notifications about new content as well as useful worksheets and additional resources only available to Your GPS Doc subscribers.