Health Care MarketplaceNews & Research

Special Enrollment Period for Major Medical Coverage

Open enrollment for major medical coverage runs in the fall each year. For 2019 health insurance, you’ll have from November 1 through December 15 to choose a health plan or change an existing policy. Outside of that open enrollment period, the only chance you have to get private major medical coverage – the kind you get if you don’t have options via work – is through a special enrollment period. In certain situations, this Affordable Care Act provision can help you gain a traditional health plan even if you’ve missed the standard signup window. But special enrollment periods aren’t available to everyone, and they can’t always help you buy a brand new policy (i.e., your first plan of the year). Understanding the ins and outs of special enrollment periods could help you get coverage you need when you need it.

Open Enrollment

As we mentioned above, Americans have the opportunity to sign up for individual or family health insurance plans just once a year, which takes place in the fall. If you miss this window, you may not have another opportunity to buy a major medical plan until the following year. For both 2018 and 2019 health insurance signups, the federal government has limited this open enrollment period to about six weeks. Before last year, the open enrollment period lasted for three months. Some states still abide by that schedule. But in almost every state, enrollment runs from November 1 through December 15 for coverage starting on January 1.

Of course, life changes fast, and it doesn’t always change on a neat schedule that aligns with open enrollment. Rules about insurance signups might be strict, but there are some permissible exceptions. The ACA included a special enrollment period as an option for people who experience a significant change in life circumstances during the year. To qualify, you must meet specific guidelines.

Qualifications for a Special Enrollment Period

Certain qualifications will allow you to get a brand new policy no matter the time of year, but most will only allow you to switch from one major medical plan to another. In other words, you have to have a major health insurance plan in place already to take advantage of a special enrollment period in many cases.

Brand New Coverage

In limited circumstances, you can use a special enrollment period to sign up for your first major medical plan of the calendar year. You don’t need to provide proof of previous coverage to qualify. These circumstances include:

  • Having a baby, adopting a child or receiving a foster placement
  • Getting released from prison
  • Increasing your income to the point that you’ve moved out of the Medicaid coverage gap and now qualify for premium tax credits

These situations give you a chance to sign up for a health insurance policy outside of open enrollment, and you don’t need to already have a health plan in place to do it.

Changing Plans

For most life changes, however, the ACA requires that you already have a policy in place to take advantage of a special signup period. Unless you’ve been covered by a major medical plan at some point in the last 60 days, you won’t be able to claim a special enrollment period for these situations. This type of signup window is designed to allow you to switch plans at times when your original coverage is no longer available to you. Examples include:

  • Losing job-based insurance
  • Losing Medicaid or pregnancy-based insurance coverage
  • Getting married, divorced or legally separated
  • Moving to an area where your previous plan is no longer available
  • Increasing or decreasing your income, which may change your eligibility for cost assistance

While these situations still open up an enrollment period for you, it’s not meant for people who haven’t been covered before. Instead, you’ll be given the chance to switch to a new health plan that meets your new needs. If you get married, for instance, then you might want to switch to a new family health plan that includes coverage for your spouse.

Non-Qualifying Events

Not all changes make it possible for you to get a special enrollment period. In particular, you won’t qualify for a special signup window if you:

  • Voluntarily drop your health insurance
  • Lose your coverage because you didn’t pay your premiums
  • Have a short term health insurance plan and the contract for it ends

These events will all result in your losing your health insurance, but they don’t count as a situation that opens up a special enrollment period. Since short term health insurance doesn’t count as minimum essential coverage, losing your coverage won’t let you enroll in a major medical policy outside of open enrollment.

How to Apply for Health Insurance Outside of Open Enrollment

If you aren’t sure whether you qualify for a special enrollment period, your best option is to go ahead and start the application process. Answering the screening questions will help determine your eligibility. You can apply for a special enrollment period through the health insurance marketplace or through an off-marketplace source.

On the Marketplace

When you visit the federal marketplace at outside of the normal signup period, you’ll be greeted with a reminder that open enrollment has ended (assuming it’s not during the November 15 through December 1 window). Look closely, however, and you’ll spot options for special enrollment.

The federal marketplace presents two different options. If you don’t have major medical coverage, click “See If I Can Enroll.” If you currently have a health insurance plan or just recently lost coverage, choose “See If I Can Change.”

After selecting one of those options, you’ll be given the chance to use the screening tool or to fill out an application. The screening tool is a fast way to learn whether you might be eligible, but it doesn’t serve as a final ruling on the matter. The application, on the other hand, is a process through which you can receive an official determination of eligibility.

Off the Marketplace

The process for applying through an insurer, agency website or independent marketplace (like this one) is similar, but it may vary among companies. Look for wording on the insurer’s website that references special enrollment periods or qualifying life events. Click the corresponding link, and you’ll probably be taken to a screening tool. Fill in the required information to begin the process.

Special enrollment periods can be confusing. If you need help to determine your eligibility, you can reach out to the federal or state marketplace call center depending on where you live, which can give you guidance on how to shop using a government exchange. For help from a non-government source, you can contact an insurance agent or a broker. Independent insurance exchanges and private health insurance companies also have representatives who can help.

Heads Up: You’ll Need Proof

The government won’t just take your word for it that you’ve experienced a major life change and need a special enrollment period. You’ll be required to submit proof that you meet the necessary qualifications. For example, if you’re claiming a special enrollment period because you got married, you may need to submit a marriage license. If your claim is based on losing your previous major medical policy, you may need to submit the paperwork that you received from that insurer.

After submitting your application, you’ll receive a notice if documentation is necessary. If you don’t get a notice, then nothing is required. The government has cracked down on this requirement, too, since plenty of people were abusing the special signup period in the past. Be prepared to back up your request with the right documents.

Electronically uploading the documents to the marketplace is the fastest and easiest submission method, but you’ll also have the option to mail photocopies. You’ll be given a 30-day window for completing the process, and you won’t be able to use your health insurance until you’ve done so.

Dates to Keep in Mind

Important dates vary depending on why you need a special enrollment period, but there are some general dates and deadlines to keep in mind if you plan on applying for one.

Application Dates

You should apply for a special enrollment period within 60 days of your situation. The sooner you apply, the sooner your new coverage can begin. For some life changes, you may be able to submit your application up to 60 days ahead of time. This advance availability may be helpful if you know that you’ll be:

  • Moving
  • Losing your job-based coverage
  • Getting released from prison

These situations typically come with some advanced warning, so look into your health insurance options ahead of time if you know that you’re going to lose your coverage.

Start Dates

Major medical coverage that you buy during a special enrollment period usually begins on the first day of the month after you apply. If you submit your application in the first half of one month, your coverage may begin on the first day of the following month. If you wait until the second half of the month to apply, your plan might not start until the first day of the month after next. If you apply on February 11, for instance, then your coverage could start on March 1. But if you waited a week and applied on the 18th, your coverage may not start until April 1.

The rules differ a bit for special enrollment periods triggered by births, adoptions and foster placements. Your new coverage can start retroactive to the date that your child first joined your family. So for example, if your son is born on August 13 but you wait to apply for coverage until the end of September, his coverage could be effective back to his actual birth date.

Note that no matter when you apply for health insurance during a special enrollment period, your coverage won’t start until you’ve submitted the required documents and paid your first month’s premium.

When Can I Buy Health Insurance?

If you’re new to health insurance or this is the first time you’ve had to buy coverage that isn’t from your job, then there are some important things to know about when to sign up. Contrary to what you might think, you can’t buy health insurance whenever you want – at least not major medical. There’s a set time each year when you can get healthcare coverage, whether you buy it from an Obamacare marketplace, directly through an insurance company or via an independent website like this one. This period is known as open enrollment, and it’s important to understand how it works if you’re in the market for a health plan that isn’t sponsored by your employer.

Why the limit?

Knowing about open enrollment is critical because, for most people, this is the only time period during which you can purchase a private health insurance plan for the upcoming year. Once this period ends, you may not be able to sign up for a major medical plan until enrollment re-opens the following fall. This applies whether you plan to purchase insurance through the healthcare marketplace or outside the exchange.

This restriction is designed to keep people from waiting to purchase major medical insurance until they have a health need. Before the ACA, insurers could deny applicants based on their health history, so waiting until a health crisis to apply for insurance was a risky gamble. The ACA now mandates that insurers accept all applicants regardless of pre-existing conditions or health status, so open enrollment is a way to encourage people to buy insurance before a medical crisis comes up.

Your health insurance premiums go towards paying for the cost of your medical care, along with the premiums of everyone else enrolled in your health plan. Just as having auto coverage protects you from shelling out thousands in repair bills during a fender-bender, having health insurance gives you a safety net during medical problems. And just as you can’t buy auto insurance right after a wreck, you can’t buy health insurance right after you get sick if it’s outside of open enrollment. The limit exists to keep everyone’s premiums down (including yours).

What to Do During Open Enrollment

Even if you like your current health plan, open enrollment gives you the perfect chance to shop around and see if there’s something better out there. Plans change from year to year, and you might find more options in 2019 than you did last year. If you’re shopping through the marketplace, start by filling out an application and learning whether you’re eligible for a premium tax credit. This subsidy reduces your costs for monthly premium payments. You can get this tax credit off the exchange if you work with an independent broker, but the plan must still come from an exchange. Not sure what that means? We can help you.

Next, survey the insurance options that are available to you. Most plans fall into the gold, silver and bronze tiers. You may also have access to platinum or catastrophic options. When comparing plans, consider both their premium amounts and their out-of-pocket costs to help you determine which one is right for you.

Once you figure out which plan best suits your needs, commit to buying it. This might seem like something that doesn’t need to be said, but we need to say it: Make sure you pay your premium. Because open enrollment falls during the holiday season, you might not put it high on your priority list. It’s easy to forget that final step of making the first premium payment. But if you don’t make your payments, your coverage can be canceled. It’s one of the few reasons that insurers can drop your coverage under the Affordable Care Act, and you don’t want to start the new year without a plan in place.

Open Enrollment 2019 Dates

Open enrollment for an Obamacare 2019 plan will take place at the end of 2018. The federal open enrollment period will begin on November 1, 2018, and will close on December 15, 2018. Residents of most states will have only those six weeks to browse the selection of plans on and off the marketplace and sign up for one.

Some states set their own open enrollment dates, so residents of those states may have longer to select a plan. If you live in California, Colorado, Connecticut, the District of Columbia, Idaho, Maryland, Massachusetts, Minnesota, New York, Rhode Island, Vermont or Washington, you may be able to begin shopping for plans sooner or wait until the end of December or January to finalize your selection. That’s because these states run their own exchange sites and regulate them differently. Check with your state’s exchange site to confirm the exact dates of open enrollment in your area.

Plans purchased during the federal open enrollment period all go into effect on January 1, 2019. If you live in a state that allows later signups, your first effective date might be after January 1.

Missing Open Enrollment

It’s critical that you commit to an Obamacare plan before the end of open enrollment because you might not have another option for when to buy health insurance. But if you do miss open enrollment, there may be another way to get coverage. Look into whether one of the following exceptions might help you get health insurance in 2019:

  • Special enrollment period: Experiencing a major life change might grant you the opportunity to buy health coverage outside of open enrollment. Major life changes include getting married, having or adopting a baby, moving, or losing your job.
  • Medicaid and/or CHIP eligibility: These government-sponsored healthcare programs aren’t subject to the rules of open enrollment. If you qualify, you can enroll any time throughout the year.
  • Native American enrollment: Members of federally recognized Native American groups can sign up for insurance during the first half of any month.
  • Job-based insurance: If a member of your family is hired by an employer that offers group health insurance, you’ll have at least 30 days to join that plan.

Medicaid and CHIP

Although most major medical coverage requires that you sign up during open enrollment, government-sponsored programs for low-income individuals and families are not bound by this restriction. You can sign up for Medicaid or the Children’s Health Insurance Program (CHIP) throughout the year. These programs provide free or low-cost medical insurance to enrollees.

Each state sets its own rules for who qualifies for its Medicaid program. In some states, anyone with a household income under 133 percent of the federal poverty level can enroll. Other states set stricter regulations. Sometimes, these programs are open only to children, pregnant women, parents or those with disabilities.

If you qualify for Medicaid or CHIP, you don’t have to wait for open enrollment to apply. You can sign up at any time. How soon your coverage can begin depends on the policies in your state. Filling out a health insurance application on the healthcare marketplace is one way to find out if you’re eligible for one of these year-round programs. You can also check with your state’s Medicaid department or talk to an insurance broker.

Different Rules for Medicare

Older adults who are eligible for Medicare must abide by an annual enrollment period, but it’s not the same as the open enrollment period for the healthcare marketplace. If you’re 65 or older, your Medicare enrollment period for 2019 runs from October 15 to December 7. There’s a separate enrollment session for changes to Medicare Advantage. This period starts on January 1 and ends March 31.

Special Enrollment Periods

Significant life changes can happen throughout the year, and the ACA makes provisions to allow people to obtain healthcare coverage at those times. When you experience a qualifying life event, you typically have up to 60 days from that date to purchase a new major medical insurance plan or switch your insurance plan. As we mentioned above, qualifying life events including moving, having a baby or changing your marital status, among other things. Losing your major medical coverage can also qualify you for a special enrollment period, but losing a short term health plan does not.

The federal government sets specific rules about who qualifies for special enrollment periods and when the new coverage can begin. Visit the federal healthcare website or consult an insurance broker to learn more about whether this provision can help you obtain health insurance in 2019.  You can be connected with a licensed insurance broker by calling our phone number.

What is Obamacare?

If you miss the ACA 2019 signups and aren’t eligible to obtain major medical insurance by other means, consider purchasing a short term health plan instead. This type of insurance is not as comprehensive as major medical coverage, but you can sign up all year long. In 2019, you’ll have the option to keep a temporary health plan for nearly a full year, and you may be eligible to renew it for a total coverage period of up to 36 months.

Where Can I Buy Health Insurance?

As someone without job-based health insurance, you might feel a pang of jealousy when your corporately-employed friends talk about enrolling in group health insurance through their HR departments. Without having a specific set of employer-sponsored plans to choose some, you might not even know where to begin the process of shopping for a major medical plan. Despite what you might think, however, enrolling in an Obamacare plan doesn’t have to be a complicated process. Whether you want to complete the signup on your own or get help from a professional, you have multiple options available to you as shop for health insurance in 2019.

State or Federal Marketplace

As we touched on above, the Affordable Care Act established insurance marketplaces where consumers can apply for major medical insurance. The federal government runs the main health insurance marketplace at, which is what most states use.

But some states have their own insurance marketplaces. Residents of those states must use those separate sites for finding major medical coverage. If you aren’t sure where to buy health insurance in your state, you can start your search at After inputting your state, you’ll be directed to the appropriate marketplace for your location. Here’s a list of locations with their own exchange sites as of 2018:

  • California
  • Colorado
  • Connecticut
  • District of Columbia
  • Idaho
  • Maryland
  • Massachusetts
  • Minnesota
  • New York
  • Rhode Island
  • Vermont
  • Washington

To receive advance premium tax credits or cost sharing reductions, your transaction must be processed through the insurance marketplace or an approved affiliate. This doesn’t mean that doing your own shopping on the marketplace is the only way to take advantage of these savings; there are ways to get help from others and still apply for cost assistance. But you do need to buy a marketplace plan – even if it’s through a broker or private marketplace – to take advantage of any cost assistance options.

On the other hand, the government-run marketplaces don’t include every health insurance plan that’s available in an area. Some insurers don’t participate in the exchanges, so their plans don’t appear on marketplace websites. Plus, you might find a better deal off of the exchange if you don’t qualify for cost assistance. Whether or not you qualify for tax credits, it’s a good idea to shop around instead of limiting yourself to only the plans that are available through the Obamacare 2019 exchange.

Directly from an Insurer

The Obamacare system was designed to help people without employer-sponsored health insurance easily purchase coverage by creating marketplaces to shop for plans. But before those marketplaces existed, you always had the option to buy a health plan directly from an insurer. And that hasn’t changed. If you feel comfortable with the process and know which company you want to buy from, you can take care of the enrollment process entirely on your own. Online marketplaces managed by insurers put the necessary signup tools right at your fingertips.

Most insurers offer the option to buy a plan directly from them. Perhaps you’ve had a plan through a particular insurer in the past, or you’ve heard good things about an insurance company from family or friends. You can visit the company’s website to learn more about the plans that are being offered for 2019.

Various insurers offer different methods of purchasing their plans. You might be able to apply online, or the site might direct you to request a quote or call for more information about signing up.

Note that buying your plan straight from the insurance company could disqualify you from getting cost assistance for which you’d otherwise be eligible. If your income falls within the guidelines for tax subsidies, make sure that your signup method allows you to take advantage of any available savings. An insurance company representative can advise you about the best way to purchase a subsidized plan.

It’s possible that you’ll have a greater variety of plan options if you work with the insurer directly instead of going through the healthcare marketplace. Some insurers don’t participate in the marketplace at all. Others may offer only a limited portion of their plans on the exchange, and their off-exchange plans might feature lower prices.

Independent Online Seller

By shopping off-exchange websites, you can see plans that are available outside of the marketplace, but going through individual carrier sites one by one can be time-consuming and confusing. Independent online marketplaces allow you to compare ACA 2019 plans from an assortment of insurance companies. This can simplify the process of finding the best healthcare coverage for your needs.

Some online sellers work in conjunction with the government-run marketplace, so you can go through them to purchase a plan with subsidies or cost-sharing reductions. One advantage of shopping this way is that you can easily compare the costs and benefits of both on-exchange and off-exchange major medical insurance plans to find the best deal.

Independent marketplaces might not partner with every insurer offering plans in your area. If you’re not sure which plan works better for you, or you wonder whether there might be something even better out there, talk to an agent or marketplace rep about your options.

Get Help with the Process

You don’t have to shop for insurance entirely on your own if you don’t want to. Whether you’re new to purchasing Obamacare plans or you simply find it reassuring to receive input about your decisions, there are professionals who can help.

Marketplace Call Center

Instead of filling out a application online, you can speak to the representatives at the Marketplace Call Center. They can help you understand the plans that are available to you, and they can walk you step-by-step through the application process. Representatives will also make sure you’re getting the cost assistance available to you. Note that exchange representatives are not sales agents, so they can’t make recommendations like an agent or broker could.

Agents and Brokers

Insurance agents usually represent one health insurance company. If you know which company you want to purchase major medical coverage from, you can go through an agent to do it. The agent will receive a commission from your purchase.

Some agents can help you buy a plan through the healthcare marketplace so that you can sign up for subsidies and cost-sharing reductions. For this to be an option, agents must represent an insurer that participates in the exchange, and they must be approved to help consumers purchase marketplace plans.

Similar to agents, health insurance brokers usually offer plans from multiple companies. They may be able to help you compare on-exchange and off-exchange plans. As with agents, brokers receive a commission if you buy a plan through them. You can visit a broker in person or use an online portal.

Some brokers can help you enroll in marketplace plans so that you can take advantage of cost assistance programs. Not all brokers are qualified to do this, so if you’re eligible for subsidies, be sure to look for a broker who’s authorized to sell marketplace plans.


Every state has navigators who provide free help to those who are signing up for marketplace health plans. These are individuals or organizations that receive special training, which equips them to help consumers compare ACA 2019 plans, apply for cost assistance and complete the signup process. They must provide unbiased guidance. As with the Marketplace Call Center, these representatives are not sales agents and can’t steer you toward a particular plan. You may be able to find a navigator in your local community. However, the Trump administration has made changes that allow some navigators to maintain a digital presence in the community instead of being physically present.

No matter how you shop for health insurance in 2019, know that you’ve got plenty of options for finding the right major medical coverage for your needs. And if you need help, just ask. From government-run programs to independent broker sites, several entities exist to help you navigate the complex world of health insurance.


CBO Blames Loss of Individual Mandate for Higher Uninsured Rate by 2028

In May, the Congressional Budget Office (CBO) and the Joint Committee on Taxation (JCT) updated estimates for the number of non-institutionalized citizens under age 65 who will have health insurance between 2019 and 2028. The report indicated that, in several categories, health insurance enrollment would decline due to the elimination of the federal mandate requiring people to have health insurance. In addition, the report found that the elimination of the federal mandate could also lead to a rise in insurance premiums as healthier people choose not to have insurance, leaving fewer healthy people and more people with higher medical costs in the marketplace.

Projected Coverage

According to the report, 89 percent of those who are under the age of 65 and who aren’t institutionalized will have health insurance in 2018. The majority of those consumers will obtain coverage from employment-based plans and Medicaid. That number drops to 88 percent for 2019 and 2020, and to 87 percent for the remaining years up through 2028. Approximately 158 million people, or 58 percent, obtain health insurance through their employer. The report found that number would decline to 154 million, or about 55 percent, by 2028.

Nongroup coverage, which is a much smaller share of the marketplace and represents anyone not covered by a job-based plan, currently accounts for about 15 million consumers per month, with 9 million purchasing their healthcare from the ACA marketplace. The CBO estimates that this number will fall by 3 million in 2018 and 2019.

Individual Mandate Elimination

In January 2018, Congress passed the Tax Cuts and Jobs Act, which effectively ended the individual mandate that required everyone in the United States to have health insurance or face a tax penalty. Starting in 2019, there is no penalty for those who do not have health insurance coverage. The mandate was the most unpopular aspect of the ACA and it was a hot topic during the 2016 election, with Republicans vowing to not only repeal the mandate but to eliminate the ACA completely. Although lawmakers were unsuccessful in repealing the ACA, the tax bill was able to eliminate the mandate.

Impact on Health Insurance Numbers

According to the CBO and JCT report, a large percentage of those in the marketplace will lose coverage, either through voluntarily ditching their health plans due to the repeal of the individual mandate or because the resulting higher premiums from a sicker risk pool will force people with medical problems to drop their coverage.

By 2028, it’s expected that about 35 million Americans won’t have health insurance, compared to 29 million in 2018. This number is 3 million higher than predicted in September 2017, before the individual mandate was repealed.

Higher Premiums

The repeal of the individual mandate is also expected to cause a rise in healthcare premiums for benchmark marketplace plans by 15 percent. Overall, premiums are expected to increase by 7 percent each year between 2019 and 2028. The rise in premiums is expected due to healthier people leaving the marketplace, leaving a higher percentage of people with medical issues that require costlier medical care. Because insurance companies are required to cover individuals with pre-existing conditions, higher medical costs must be absorbed by increased premiums if healthier individuals aren’t there to offset these costs.

Lack of Options

Although the CBO report indicates that the marketplace will remain stable in 2019, there is some speculation that the elimination of the individual mandate could undermine the market. Currently, there are areas of the country where consumers in the marketplace have only one option for insurance. Should that insurer choose to leave the marketplace due to higher medical costs it can’t absorb, this could leave consumers with no options for health insurance. Some states may expand Medicaid eligibility under guidelines from the Affordable Care Act, which would help consumers obtain insurance. However, health experts also theorize that some states will push for short-term, non-ACA compliant policies, which could further undermine the major medical marketplace.

Although the individual mandate was unpopular regardless of political leaning, it was put in place to encourage healthier people to purchase health insurance so that their premiums could offset the costs of medical treatments for people with health problems. The CBO and JCT report indicates that elimination of the mandate may further reduce the number of people who have health insurance and could have a negative impact on premiums as well.

Need Health Insurance? Time’s Running Out for 2018 Coverage

Open enrollment for the Affordable Care Act (ACA) ends Friday, December 15. This is the only time during the year that you can purchase or change your major medical insurance unless you experience a qualifying life event, like a significant death in the family or the birth of a child. The purpose of open enrollment is to prevent you from buying health insurance only when you get sick, which can drive up the cost of care. Here are some things to keep in mind as enrollment wraps up for the year.

Shorter Enrollment Period

The enrollment period for 2018 coverage is shorter than it has been in previous years. Last year, open enrollment lasted for three months, but this year, the Trump administration reduced the length of time you had to enroll to just 45 days, from November 1 through December 15. In an effort to assist residents, nine states have extended the open enrollment period for their state-operated exchanges. The states and their enrollment deadlines include:

  • California (January 31)
  • Colorado (January 12)
  • Connecticut (December 22)
  • District of Columbia (January 31)
  • Massachusetts (January 23)
  • Minnesota (January 14)
  • New York (January 31)
  • Rhode Island (December 31)
  • Washington (January 15)

This means that if you are resident of these states, you have longer to change or sign up for health insurance under the ACA. Residents of hurricane-affected states, such as Florida and Texas, will also have extra time to sign up for health insurance this year. If you live in an area that was devastated by hurricanes earlier this fall, then you’ll need to call the marketplace call center for information on the extended deadline of December 31.

Penalties Still in Force

Many people are under the mistaken belief that the individual mandate that requires you to have health insurance or face an income tax penalty has been eliminated. Although President Trump signed an executive order that allows government agencies to relax regulations related to collecting the penalty, including leniency when taxpayers claim hardship related to the ACA, the law is still in place, and so is the fine.

In December 2017, the Senate passed a tax reform bill that would eliminate the individual mandate, but that will not take effect until 2019 if it’s adopted as is. This means that you are still required to have health insurance or face a tax penalty of $695 per adult or 2.5 percent of your income, whichever is higher. Congress hopes to have the bill ready for President Trump’s signature by Christmas.

ACA Uncertainty

Another reason to sign up for health insurance under the ACA before the deadline is that there could be significant changes to the law for 2019. During the presidential campaign last year, many Republicans were elected on a platform that promised to either completely repeal the law and replace it with a better version or to fix problems with the ACA that were causing premiums, deductibles and co-payments to rise. Several bills have been proposed in Congress, but none have been successful. For this reason, Republicans have suggested using the new tax reform bill to end certain portions of the ACA under the Senate’s reconciliation rules. Experts believe that eliminating the individual mandate will drive up premiums that will keep healthy people, whose premiums help offset the cost of care for people with pre-existing conditions – and who don’t want to purchase health insurance in the first place – from buying policies.

Elimination of Cost-Sharing Payments

In October, President Trump suspended federal cost-sharing payments for insurers. These payments reimburse insurance companies so that they can lower co-payments and deductibles for lower-income families. Anyone earning up to 250 percent of the federal poverty level qualifies for additional cost-sharing reductions, which are still in effect. The problem is that now insurers can’t be reimbursed for lowering out-of-pocket costs, like copayments and deductibles. In other words, insurers stand to lose money.

As a result, premiums for silver-level plans in particular have skyrocketed this year, leaving plenty of Americans with a tough choice to make on buying health insurance. But there are still affordable options in other metal tiers, specifically gold plans, which provide better coverage. Premiums will likely continue to rise next year since insurers can’t count on those cost-sharing reduction payments from the government, so now’s the time to check out your options.

Changes to 2019 Marketplace Rules

In November 2017, the Trump administration issued its proposed “Notice of Benefits and Payment Parameters,” rules that are issued each year to set standards for insurance policies sold under the ACA. The new rules loosen restrictions regarding the essential health benefits included under the ACA and gives states latitude in what essential health benefits must be included. The rule also eliminates a requirement that each state have two “Navigator” entities, people who are available to assist any individual who may not understand the ACA.

The proposed rule also reduces accountability requirements for insurers and makes it less likely that insurers will prominently display “simple plans,” plans that offer flat copayments for doctor visits and generic drugs, but charge higher fees for other types of services. These new rules could mean that basic benefits available under the ACA in 2018 may not be as readily available in 2019, another reason to sign up for healthcare during the open enrollment period for next year.

Higher Premiums

There has been much talk of higher premiums for coverage under the ACA for 2018. In some cases, this is true due to the elimination of the cost-sharing reduction payments as described above. In some areas of the country, there may be fewer insurers, which can also drive up premium prices. Nationally, the lowest cost bronze plan is expected to increase by 17 percent, the lowest cost silver plan by 32 percent and the lowest cost gold plan by 18 percent. However, the subsidies that are still in place could lower premiums significantly. A 40-year old person making $35,000, which is 249 percent of the federal poverty level, will pay 36 percent less for the lowest cost bronze plan, 6 percent less for the lowest cost silver plan and 12 percent less than the lowest cost gold plan.

This indicates that although some premiums may increase, many will actually decrease in 2018. Plus, tax subsidies to reduce premiums rise along with the higher premiums, so if you qualify for cost assistance – anyone earning up to 400 percent of the federal poverty level qualifies – then check out your options for next year.

If you don’t sign up for coverage before December 15 or if you don’t make necessary changes by that date, you won’t be able to make the changes or sign up until the next enrollment period. The only exceptions are for life-changing events, like loss of job, a marriage, divorce or a big move. In addition, you will face an IRS penalty at the end of the year when you file your taxes if you can’t prove that you had coverage. Signing up for health insurance is the best way to avoid the IRS penalty and make sure your family is protected for next year.

When You Need Major Medical Insurance and When You Don’t

When You Need Major Medical Insurance – and When You Don’t

Buying health insurance is no simple task. Even armed with the right knowledge, understanding the options available to you can be tough, especially if you’re new to the process or you don’t see a doctor very often anyway. Do you even need health insurance? Plenty of people get stuck on that very question. If you’re young, healthy and have no dependents to take care of, then you may be able to forgo health insurance – or bundle some standalone products together to create a different kind of insurance package. But not everyone has the luxury of skipping out on health insurance. From chronic medical problems to taking care of a family, there are valid and important reasons to buy major medical coverage each year.

Should you buy health insurance? That depends.

Even if you can justify avoiding health insurance, you may not come out ahead, for a couple of reasons. First, you may face an unexpected medical crisis – a broken back, for instance, or a cancer diagnosis – and without medical insurance, you could be on the hook for hundreds of thousands of dollars. Worst-case scenario? You might bankrupt yourself trying to cover your medical bills and still not get the adequate treatment that you need. Second, there’s an individual mandate in place under the Affordable Care Act (ACA or Obamacare) requiring most people to have qualifying health insurance. If you don’t, then you’ll face a penalty fee for not complying with the law.

The mandate has been in effect since the start of Obamacare, but people still seem to be confused about what it means. We explore the individual mandate in more detail in another article. Here, we want to talk about the price tag of this key ACA provision and how it might factor in when you’re deciding whether to buy major medical insurance or not. For some, skipping health insurance and paying the fine can be more economical. For others, affordable – if somewhat basic – plans are available that cost just as much as the fine. Let’s crunch the numbers on the individual mandate.

Note: We’re using the individual mandate penalty calculator and the subsidy calculator developed by the Kaiser Family Foundation for our estimates. For consistency’s sake, our example customers live in Ringgold, Georgia, a small town at the top of that state. Georgia ranks third among the states with the highest spike in premiums for 2018. We’re also assuming that our example customers cannot get coverage through work.

Health insurance makes sense for some.

Example 1: Kevin, a single man with no dependents and a pre-existing condition

Kevin is in his mid-30s, lives alone and has no dependents. He earns about $45,000 a year. Kevin has diabetes and has to take several medications each month. He also visits his doctor regularly for screenings, checkups and lab work. Here’s how the individual mandate stacks up against the lowest-cost health insurance plan on the marketplace for Kevin:

  • Individual mandate: The penalty fee for not having health insurance in 2017 is the greater of 2.5 percent of a person’s taxable household income, or a flat $695 fee per adult. Kevin’s taxable income ($45,000 – $10,400 [tax threshold for individuals]) is about $34,600. If you multiply that figure by 2.5 percent, you get $865. Since $865 is higher than the flat fee amount, Kevin would owe $865 when he files his taxes if he didn’t buy health insurance. That’s about $72 a month (if it were paid monthly), and he doesn’t benefit from that payment. He would have to cover all of his medical costs on his own.
  • Health insurance: Kevin’s income puts him at about 373 percent of the federal poverty level. He earns too much for cost-sharing reductions, but he’s still within the limits for regular tax credits to bring down his premiums. The lowest-priced plan in Kevin’s area would cost him $194 a month after his tax credit. But because Kevin needs more medical care than a bronze plan would cover, he’s more likely to get a silver or even gold plan. In that case, his cost would jump to about $359 a month after subsidies for silver-level coverage.

Even though it seems like Kevin could save money during the year by not having major medical coverage, he should still buy a plan. He’s got a chronic health problem (a pre-existing condition), and he’ll need more care as he gets older. Five years ago, people with diabetes required nearly $14,000 a year in medical care. Costs rarely go down in the medical world. Obamacare places a cap on how much people with health insurance have to spend out of pocket on medical costs. In 2018, that’s $7,350 a year for an individual with a silver plan.

Between monthly premiums (which don’t count toward the annual cap on expenses) and various out-of-pocket costs up to that maximum, Kevin might end up paying over $11,000 for the year for healthcare. But in that same year, he would have gotten the care that he needed and actually saved money over what a person with diabetes typically costs. If he didn’t have health insurance, he might forgo doctor’s visits, skip prescriptions and develop more problems in the future.

The example of Kevin isn’t even an extreme one, since he’s a single guy without any kids and just one health problem. Imagine if he had kids, a spouse, less income or more than one medical issue – as is the case for millions of Americans. Many low-income individuals, too, should invest in health insurance. In some cases, the lowest-priced bronze plan on the exchange could cost substantially less than paying the penalty fee for the year, and you’d have coverage if you needed it. Health insurance makes sense from practical and economic standpoints in these scenarios.

Paying the fine might work out better for some.

Example 2: Kevin’s twin sister, Stacy, who also has no dependents but doesn’t have a pre-existing condition.

Stacy, like Kevin, is in her 30s and lives alone. She works in a similar field but earns substantially less than her brother – about $35,000 a year compared to his $45,000 salary. Men earn a great deal more than women, on average, in the counties that surround Ringgold, Georgia. Unlike her twin brother, Stacy does not have any health problems, and she rarely sees a doctor. Here’s what the cost of the mandate vs. health insurance might look like for Stacy:

  • Individual mandate: Using the same information that we used for Kevin, we can calculate Stacy’s taxable income ($35,000 – $10,400 [tax threshold for individuals]) to be about $24,600. If you multiply that by 2.5 percent, you get $615. Since that’s less than the flat fee of $695, Stacy would pay the flat fee rate for not having health insurance. That divides out to about $58 a month.
  • Health insurance: Stacy’s income puts her at about 290 percent of the federal poverty level. The cutoff for cost-sharing subsidies is 250 percent, but she does still qualify for regular tax credits, like her brother. In Stacy’s case, tax credits would reduce her premiums for the lowest-priced plan in her area to about $106 a month. That’s nearly twice what she would pay for the individual mandate penalty. And unlike Kevin, Stacy has no medical problems and doesn’t need extensive coverage. If she wanted to join a silver plan, she’d have to pay about $270 a month after subsidies.

Premiums aren’t the only cost that Stacy would have to cover during the year. Until she met her deductible – which averages to over $5,700 for a bronze plan in 2018 – she would have to cover most medical expenses herself. Once she met the deductible, she’d still be responsible for out-of-pocket costs. Unlike her brother, Stacy probably won’t meet her out-of-pocket cap for the year because she hardly sees a doctor for anything other than preventive care.

She would be paying high monthly premiums (as a portion of her income) and have to meet an absurdly high deductible to benefit from major medical insurance. In Stacy’s case, paying the fine and getting a bundle of ancillary products or a short-term policy instead would make more economical and practical sense.

Who else might be able to get away with not having health insurance? Generally, this approach only works for people with few or no medical problems who are young and don’t have dependents to take care of. But families might also forgo major medical coverage, at least for the adults, if their kids qualify for the Children’s Health Insurance Program (CHIP). All states have this program to some degree. In Georgia, for example, kids can qualify for the CHIP program if their families earn too much for Medicaid but fall within certain low income parameters.

On the opposite end of the spectrum, a person who earns too much for subsidies but can’t afford major medical insurance could afford to pay the fine, buy short-term policies or standalone ancillary products, and probably come out ahead barring any life-changing medical disasters.

So, do you need major medical or not?

The answer depends on a few things, namely your health, your income and your comfort level with assuming certain types of risk. It’s risky to go uninsured, especially if you’ve got family history of health problems or are getting older. Accidents, too, can happen to anyone at any age. In fact, they’re the fourth leading cause of death overall in the U.S. (number one for ages 1 to 44). Cancer is number two. You can’t predict what will happen from year to year with your health.

But if you’re reasonably sure that you don’t need coverage – or you simply can’t afford the premiums even with subsidies – then you may be able to forgo health insurance, buy cheaper non-major medical policies instead (for “what-if” scenarios) and pay the individual mandate penalty. If you want to see the numbers for your specific situation, check out the calculators linked above on the Kaiser Family Foundation website. And if you need help sorting through your options, talk to a licensed health insurance agent today for more information.

OEP State Deadlines

Each year, the federal government sets open enrollment dates to sign up for health insurance as required by the Affordable Care Act (ACA or Obamacare). This is the one time a year when people throughout the country can sign up for, change or renew their coverage for the following year. Open to anyone who needs health insurance, specifically those who can’t get insurance through work, the open enrollment period serves as a chance to review your coverage and make sure you’re getting the best deal for your healthcare needs. This year, the Trump administration shortened open enrollment 2018 to just 45 days, running from November 1 through December 15.

These dates apply nationwide, but some states have opted to expand enrollment. These states are ones that have created their own exchanges apart from the federal one at Eleven states plus the District of Columbia opted to create their own Obamacare marketplaces, and of those, nine have chosen to extend open enrollment deadlines for 2018. If you live in one of the following states, then you’ll follow your state’s guidelines for enrollment.

State Deadlines

Location Open Enrollment Deadline
California January 31
Connecticut December 22
Colorado January 12
District of Columbia January 31
Massachusetts January 23
Minnesota January 14
New York January 31
Rhode Island December 31
Washington January 15

Three additional states have state-based exchanges: Idaho, Maryland and Vermont. In Idaho, residents have until the federal deadline of December 15 to submit an application but an additional week (until December 22) to choose a health plan as long as they’ve met the federal deadline for application. Residents of Maryland and Vermont will follow the federal schedule. No matter where you live, open enrollment for 2018 health insurance starts on November 1.

Hurricane Victims to Get Additional Time During Open Enrollment 2018

The 2017 hurricane season has been one of the worst in history. Hurricanes Harvey, Irma and Maria caused significant damage in the southern United States as well as Puerto Rico and the U.S. Virgin Islands. This has led the Centers for Medicare and Medicaid Services (CMS) to extend open enrollment not only for Medicare but for the federal exchanges as well.

Open enrollment for Medicare started October 15. For all others, open enrollment to obtain health insurance in 2018 will start November 1. Victims of the hurricanes will have an additional two weeks to sign up for next year.

Extension Details

If you lived in areas affected by the hurricanes and were impacted by the storm yourself, whether it was damage, injury or forced relocation, you are eligible for the extension. Under the ACA, anyone with a life-changing event can make changes to their health insurance outside the enrollment period. CMS announced that anyone who experienced a qualifying life event 60 days prior to the hurricanes but were unable to complete the application, select a new plan or enroll in a plan due to the hurricane, now has until December 31 to complete the process.

It will also allow anyone impacted by the storms to sign up for or renew existing coverage from November 1 through December 31. Open enrollment for the rest of the country ends on December 15.

Specific States

If you live in one of the following areas affected by the 2017 hurricane season, you are eligible for the extended enrollment:

  • Florida
  • Georgia
  • Louisiana
  • Texas
  • South Carolina

Not all areas of each state are included in the extension. Only counties that were affected by the hurricanes qualify.

Displaced Consumers

If you were required to move from areas affected by hurricanes, you are also eligible for a special enrollment period through the end of the year. Those who want to take advantage of this extended enrollment offer need to contact the Marketplace Call Center at 1-800-318-2596 in order to sign up after December 15.

One of the reasons for this extension is that many who were displaced after the hurricanes cannot access financial records or other data necessary to qualify them for some of the subsidies available under the federal exchange program. Likewise, if you were required to relocate due to damage to your residence and have been unable to return, your policy may not cover services in another area of the state or country. This would require you to find another plan that will keep you covered in your new location.

State Exchanges Not Included

Because the states affected chose not to set up their own marketplaces and decided to use the federal marketplace for health insurance, all residents who qualify may use the extension program. The extension only applies to the federal marketplaces. If you are a resident of Puerto Rico or the U.S. Virgin Islands, you are not eligible to participate in the federal marketplace, but may be able to use the extension available to Medicare participants.

Earlier this year, the Trump administration reduced the enrollment period from the 12 weeks available under the Obama administration to six weeks, running from November 1 through December 15. This extension gives those affected by the hurricanes an additional two weeks to either renew or sign up for a new policy to avoid a lapse in coverage.

Price Resigns as HHS Secretary – What’s Next for the Department?

On Friday, September 29, Tom Price, Health and Human Services Secretary, resigned his position. Price had been under fire for his use of taxpayer-funded charter flights. Don J. Wright, who had been the acting assistant secretary for health and director of the Office of Disease Prevention and Health Promotion, was named acting secretary.

HHS Inspector General Probe

On September 22, it was announced that the Health and Human Services inspector general, Daniel R. Levinson, had initiated an investigation into Price’s use of chartered planes. The investigation involved more than 20 flights in recent months, all taken at taxpayer expense. Levinson, who was appointed by President George Bush, was contacted by House Democrats who believed the chartered flights violated federal law requiring officials in the executive branch to travel in the most economical way possible. It’s estimated that the flights cost taxpayers $400,000 while White House-approved travel on military planes cost more than $500,000.

Reimbursement Offer

The day before his resignation, Price announced he would reimburse the federal government $51,887.31 for his travel, only a fraction of what it cost the country. This was to cover his travel expenses but not those of his staff, who traveled with him. He also announced he would no longer take such flights due to the concerns raised about his use of taxpayer money. On Friday morning, President Trump told reporters he considered Price a “fine man” but that he didn’t care for the “optics” the scandal presented, stating that he would make a decision on what to do by the end of the day. It’s clear, however, that the president already had Price’s resignation when he made the statement.

Additional Concerns

This was not the first concern expressed by Democrats about Price. Earlier this year, there were concerns about private investments in healthcare companies that Price made while a member of the House. Those companies could have benefitted from bills he sponsored. At his confirmation hearing for secretary of HHS, Price was questioned about a stock purchase he made in 2016 in an Australian biomedical firm, which coincided with final negotiations on the 21st Century Cures bill. That bill helped accelerate clinical trials and drug approvals, some of which were manufactured by the company. Price has also come under fire from President Trump for the failure of Republicans to pass a healthcare replacement bill.

What it Means for HHS

Because Republicans failed to repeal and replace the Affordable Care Act (ACA) prior to September 30, they must now create a law that will appeal to enough Democrats for it to pass. Until that time, HHS will need to implement the law as it is. Local groups who must assist consumers in enrolling are expressing frustration with the current administration, and Democrats claim the White House is sabotaging the law. These are issues that will need to be addressed by the department as the country heads into another open enrollment period in November.

There are also questions about who may replace Price as secretary. One top contender is Seema Verma, current administrator of the Centers for Medicare and Medicaid Services (CMS), who has received bipartisan support in the past. Others include Scott Gottlieb, commissioner of the Food and Drug Administration, and David Shulkin, secretary for the Department of Veterans Affairs.

It is unclear whether Price will still reimburse the government the $52,000 he promised on Thursday as he did not mention it in his resignation letter. His letter stated that he decided to resign due to the distraction the travel scandal was having on the administration.

Changes to Advertising for Open Enrollment 2018

Healthcare has taken center stage in national media lately, thanks in large part to uncertainty over the upcoming enrollment season for 2018. But the reality is that no new laws have been passed yet, nor does it seem likely that anything will now that a recent last-ditch effort by Republican lawmakers failed to garner sufficient support.

Still, political back-and-forth has done little to quell the anxiety of millions of Americans who rely on health insurance and who want to know what changes they can expect for next year. Some programs are undergoing alterations already, including the “Navigator” program. What is the Navigator program, and what does it mean for you? Here’s a look at some changes coming for the 2018 enrollment season when it comes to advertising – and how they might affect you.

What is the Navigator Program?

The Navigator program is essentially a provision included in the Affordable Care Act that is designed to help consumers and small businesses better understand the health insurance options available to them. Within the individual health insurance marketplaces, individuals and businesses should be able to easily understand the coverage options that are available to them in their state. In addition, it shouldn’t be difficult to find affordable options within the marketplace itself. The Navigator program is designed to be self-funded by using operating dollars coming from the marketplace.

When this program was first introduced, two types of navigators were provided for under the law. The first involves the establishment of a community-based organization focused solely on the consumer. It’s a nonprofit organization that aims to ensure consumers are armed with the knowledge they need to understand the healthcare options available to them under the ACA.

The second type of navigator is designed to encompass a trade association, licensed insurance agent or broker. This entity or person is not compensated for his or her role in selling health insurance, which prevents conflicts of interest from interfering with the job. The overarching goal is for consumers and small business to receive unbiased and informed advice from navigators in their areas.

What’s New for 2018?

In an effort to further raise awareness of the health insurance marketplace – which some people still aren’t familiar with – there will be some changes to the Navigator program in 2018. For starters, the Centers for Medicare and Medicaid Services (CMS) announced that it will spend roughly $10 million to better educate both new and returning marketplace enrollees. CMS wants to make sure that people have the information they need to make a more informed decision about which type of coverage is best for them, especially in light of all the upheaval over healthcare in recent months.

Individual consumers should begin to see more efforts aimed at providing them with information about their coverage options. It’s already been announced that information will be relayed to the public via a variety of digital media outlets, including, at minimum, a combination of email and text messages.

There will also be a stronger push on the part of the Navigator program to initiate a public relations campaign to better serve the needs of individual consumers and small businesses. Much of the financial cost that navigators will incur in 2018 will be covered by federal funding using a set formula based on enrollment goals. This is to ensure better accountability and to make certain that navigators are upholding the original intent of the program.

Open Enrollment Advertising for 2018

Upcoming enrollment for the 2018 plan year will run from November 1, 2017 to December 15, 2017. This is a shortened period in comparison to recent years, and Navigators are now tasked with the responsibility of promoting these dates to the public. Many have already begun to do so by sending out emails and text messages to individual consumers across the country. The goal now is to help explain the reduced number of healthcare options available in many regions and help customers make a more informed decision about health insurance.

It’s important to note that exchange customers will still have a number of options when it comes to signing up for coverage in 2018, including online support, call centers, insurance agents and brokers. The Navigator program will help direct consumers to a provider of their choosing based on their needs.

Advertising will be a big push this year in order to compensate for a lot of concern and misinformation being circulated in the current political landscape. There are still options for health insurance that need to be considered, and the Navigator program seeks to ensure that customers get the information that they need regardless of what’s going on in Washington at the moment.


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