The August 15 Special Enrollment Period has ended. Unless you qualify for another SEP, you will have to wait until November 1-December 15 to enroll or make a change.
For those who are not yet on Medicare and have no healthcare available through an employer, there are individual health plans. In 2010, the Affordable Care Act, sometimes referred to as Obamacare, was passed. It is a health reform law that aims to make healthcare more affordable and more widely available. The Affordable Care Act (ACA) established minimum requirements that health plans must follow. In fact, the ACA is responsible for insuring coverage of preventative services, as determined by the law.
Many insurance companies offer individual health plans that are sold on-exchange. The “exchange” is just a marketplace for the plans. It is important to understand participation in the Exchange is optional. The ACA does not force any insurer to participate. In other words, some insurers only offer plans in limited areas while some insurers do not participate at all.
Health Plan Requirements
Minimum essential coverage includes preventative services and services as necessary to treat illness. Preventative services include annual wellness visits, annual well-woman visits, annual mammograms (women over 40), prostate exams, screenings for diabetes, blood pressure, cholesterol, cardiovascular disease, cervical cancer, HIV, STDs, depression and many other services. Coverage is not required for non-essential or elective services.
Types of Health Plans
Individual health plans offered through the exchange fall into four basic categories, also known as “metal” levels. The “metal” plans include:
- Bronze plans pay 60%. These plans have high deductibles and have the lowest premiums.
- Silver plans pay 70%. These are middle of the road plans and often make the most sense financially. Premiums are higher than Bronze plans.
- Gold plans pay 80%. These plans have lower deductibles but the premiums – higher than Silver – may not be worth the difference. It really depends on each person’s circumstances.
- Platinum plans pay 90%. Of course, these have the lowest deductibles and highest payments. These may be the right choice for someone who expects to have extremely high utilization of services.
Catastrophic plans are offered to limited segments of the population. You must be under the age of 30 or qualify based on a “hardship exemption”. If you purchase a plan without meeting the requirements, you will be disenrolled.
Costs of Health Plans
Depending on income, you may qualify for a cost share reduction in premium through tax credits. In addition, some people qualify for subsidies which can lower copays, coinsurance, deductibles and maximum out-of-pocket on Silver plans. If you do not qualify for a subsidy, you may still purchase a plan.
When Can I Enroll in Health Insurance?
Generally, you can enroll in a individual health plan during the annual open enrollment period which runs November 1 through December 15. During this time, you can apply for a health insurance plan with a January 1 start date.
Outside of this annual enrollment window, you may enroll in a health plan if you qualify for special enrollment period. Special enrollment periods are life events that create a change in your circumstances. Some examples of qualifying life events include:
- Loss of coverage – this may be that you’re turning 26 and coming off your parents plan, you lose job-based coverage, lose coverage from a divorce or it’s due to death of a family member. There may be other reasons you have lost coverage and you need to be prepared to prove the loss. Keep in mind, if you are allowed to keep your current plan after the death of someone, this may not be considered a loss of coverage but you may have other enrollment considerations.
- Change in household – Some events that qualify as a change in household include marriage, divorce and the birth or adoption of a child.
- Moving to another zip code or county or moving to or from transitional housing.
- Other qualifying life events include things like becoming a U.S. citizen, changes in income and a few other scenarios, which currently includes a national Covid-19 pandemic response.
If you have questions about whether or not you may qualify for a special enrollment period, it’s always best to ask instead of assuming you don’t.