ACA Open Enrollment: If You Buy Health Coverage in the Individual Market

If you buy your health plan on your own (rather than getting coverage through an employer), you may purchase a 2020 plan either through your state’s health insurance marketplace or in the individual market outside the marketplace. If you are low-income, you may be eligible for Medicaid coverage.

What’s Covered?

All plans in the individual market must be comprehensive, covering doctor visits, hospitalization, prescription drugs and maternity care without restrictions for physical or mental illnesses or conditions that existed before coverage began. Preventive services like immunizations, screenings and birth control, are covered with no additional out-of-pocket cost. Insurers cannot charge you more based on your medical history or because you are a woman. Insurers can only vary premiums based on your age, the number of the people in your family covered by the policy, and whether you use tobacco.

What About Deductibles?

Plans sold both through the marketplace and outside of state marketplaces come in four levels – bronze, silver, gold and platinum.  The metal levels signify differences in the amount of deductibles and other-out-of-of pocket costs they require for covered benefits. In general, bronze plans tend to have the highest deductibles and lowest premiums, while gold plans generally have lower deductibles but charge higher monthly premiums. All plans are required to have an annual out-of-pocket limit on your cost sharing for covered services in-network. That limit can be no higher than $8,150 per person in 2020 ($16,300 in a family policy.) If you are under 30, you may be able to get a “catastrophic” insurance plan that charges the highest possible deductible ($8,150), with monthly premiums that are even lower than under bronze plans.

Deadline for 2020 Plan Signup

Open enrollment for plans on or off marketplaces runs from Nov. 1 to Dec. 15 of this year in most states, including those using healthcare.gov. Coverage takes effect on Jan. 1, 2020. After Dec. 15, you may only sign up for a plan under special circumstances. Open enrollment in states that run their own marketplaces depends on the state. Seven states – California, Colorado, D.C., Massachusetts, Minnesota, New York, and Rhode Island – have extended open enrollment beyond Dec. 15, 2019. Check with your state marketplace for details.

Help With Premiums and Cost Sharing

If you buy a plan through the marketplace, you may be eligible for financial assistance based on your income to help cover premiums. In general, you may be eligible if you are single and your annual 2020 income is between $12,490 to $49,960 or if your household income is between $21,330 to $85,320 for a family of three (the lower income limits are higher in states that expanded Medicaid). The range differs for families of different sizes. Although premiums for marketplace plans increase from year to year, if you qualify for premium tax credits, the tax credit should cover most or nearly all of the cost increase. You may find plans that are offered outside the marketplace, but unless you purchase plans through the marketplace,  you won’t be eligible for financial assistance.

You can also qualify for help with cost sharing if you buy a plan through the marketplace and your income is between $12,490 and $31,225 ($21,330 to $53,325 for a family of three.) Special modified silver plans are available with lower deductibles, copays, and annual out-of-pocket limits on cost sharing.

Where to Sign Up

In most states, you can sign up for a marketplace plan using the federal website, www.healthcare.gov.  In 13 states – California, Colorado, Connecticut, District of Columbia, Idaho, Maryland, Massachusetts, Minnesota, Nevada, New York, Rhode Island, Vermont and Washington – you can get marketplace coverage through state-run websites.  Nevada will transition to a state-based marketplace for 2020 coverage; previously Nevada residents used healthcare.gov.

What to Expect at Open Enrollment

If you intend to apply for financial help, you will need to have information about yourself and other household members who need insurance (names, birth dates, social security numbers, or document numbers for immigrants), information about your household income (copy of most recent tax return, or paystubs, etc.), and information about any employer coverage you might be offered.  If you are renewing coverage, you can remain in your current plan if it continues to be offered.  Generally, the marketplace will automatically renew you into your current coverage if you do nothing, but it is best to review all plan choices and update your application, even if you decide to remain in your current plan, so you will receive the most accurate financial assistance.

Questions

If you have questions, you can call the federal government’s toll-free 24-hour hotline at 1-800-318-2596. To find in-person help, go to https://localhelp.healthcare.gov. Further information is available at www.healthcare.gov and at https://www.kff.org/health-reform/faq/health-insurance-marketplace-aca/.