There will be a health insurance Marketplace in every state for individuals and families and for small businesses. Some Marketplaces will be operated by the State and have a special state name (such as CoveredCalifornia or The Maryland Health Connection.) In other states where the federal government runs the Marketplace, it will be known called The Health Insurance Marketplace of [state name.]
Not everybody who is eligible to purchase coverage in the Marketplace will be eligible for subsidies, however. To qualify for subsidies (also called premium tax credits) people will have to meet additional requirements having to do with their income and their eligibility for other coverage.
For 2016 coverage, the Open Enrollment period begins November 1, 2015 and extends through January 31, 2016. Once the Open Enrollment period is over, individuals and families will not be able to enroll in Marketplace health plans until the next Open Enrollment period. However, if you experience certain changes in circumstances during the year, you will have a special 60-day opportunity to enroll in Marketplace health plans, outside of the Open Enrollment period.
For individuals and families buying non-group coverage on their own, outside of the Marketplace, you can only enroll in coverage during Open Enrollment periods and special enrollment opportunities, as well. Call us for more information
American Indians and Alaska Natives can enroll in coverage throughout the year, not just during Open Enrollment.
- Loss of eligibility for other coverage (for example if you quit your job or were laid off or if your hours were reduced, or if you lose student health coverage when you graduate) Note that loss of eligibility for other coverage because you didn’t pay premiums does not trigger a special enrollment opportunity
- Gaining a dependent (for example, if you get married or give birth to or adopt a child). Note that pregnancy does NOT trigger a special enrollment opportunity.
- Loss of coverage due to divorce or legal separation
- Loss of dependent status (for example, “aging off” a parents’ plan when you turn 26)
- Moving to another state or within a state if you move outside of your health plan service area
- Exhaustion of COBRA coverage
- Losing eligibility for Medicaid or the Children’s Health Insurance Program
- For people enrolled in a Marketplace plan, income increases or decreases enough to change your eligibility for subsidies
- Change in immigration status
- Enrollment or eligibility error made by the Marketplace or another government agency or somebody, such as an assister, acting on their behalf.
Note that some triggering events will only qualify you for a special enrollment opportunity in the health insurance Marketplace; they do not apply in the outside market. For example, if you gain citizenship or lawfully present status, the Marketplace must provide you with a special enrollment opportunity.
When you experience a qualifying event, your special enrollment opportunity will last 60 days from the date of that triggering event. If you can foresee a qualifying event (for example, you know the date when you will graduate and lose student health insurance coverage) you can ask the Marketplace for a special enrollment opportunity up to 60 days in advance so new coverage will take effect right after your old coverage runs out.
States have flexibility to expand special enrollment opportunities for consumers. Check with your State Marketplace for more information.
After that, if you enroll between the 1st and 15th day of the month and pay your premium by the due date, your coverage begins the first day of the next month. So if you enroll on January 10, 2016, your coverage begins February 1, 2016.
If you enroll between the 16th and the last day of the month and pay your premium by the due date, your effective date of coverage will be the first day of the second following month. So if you enroll on January 16, 2016, your coverage starts on March 1, 2016.
Health plans may vary somewhat in the benefits they cover. Health plans also will vary based on the level of cost sharing required. Plans will be labeled Bronze, Silver, Gold, and Platinum to indicate the overall amount of cost sharing they require. Bronze plans will have the highest deductibles and other cost sharing, while Platinum plans will have the lowest. Health plans will also vary based on the networks of hospitals and other health care providers they offer. Some plans will require you to get all non-emergency care in-network, while others will provide some coverage when you receive out-of-network care.
- Ambulatory patient services (outpatient care you get without being admitted to a hospital)
- Emergency services
- Maternity and newborn care (care before and after your baby is born)
- Mental health and substance use disorder services, including behavioral health treatment
- Prescription drugs
- Rehabilitative and habilitative services and devices (services and devices to help people with injuries, disabilities, or chronic conditions gain or recover mental and physical skills)
- Laboratory services
- Preventive and wellness services and chronic disease management
- Pediatric services, including dental and vision care
The precise details of what is covered within these categories may vary somewhat from plan to plan.
Generally, you can only enroll in a marketplace or switch plans during the open enrollment period, unless you qualify for a special enrollment period because of special circumstances in your life, such as losing your health insurance because of divorce, a spouse’s death, unemployment or a change in income. In these circumstances, you’re allowed to enroll in a new plan or switch plans without waiting until the next open enrollment period.