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

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 2018 plan either through your state’s health insurance marketplace or off-exchange. If you are low-income, you may be eligible for Medicaid coverage. If you don’t have health coverage in 2018, you may be subject to a tax penalty.

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’S AVAILABLE

Plans both in and out 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 $7,350 per person in 2018 ($14,700 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 ($7,350), with monthly premiums that are even lower than under bronze plans.

DEADLINE FOR 2018 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, 2018. 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. Nine states – California, Colorado, Connecticut, D.C., Massachusetts, Minnesota, New York, Rhode Island, and Washington – have extended open enrollment beyond Dec. 15, 2017. Check with your state marketplace for details.

HELP WITH PREMIUMS

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 2018 income is between $12,060 to $48,240 or if your household income is between $20,420 to $81,680 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 are increasing significantly in many states, if you qualify for premium tax credits, the tax credit should cover most or nearly all of the cost increase. A plan purchased outside the state marketplace provides the same protections as plans offered through the marketplace — but you won’t be eligible for financial assistance.

HELP WITH COST SHARING

If you buy a plan through the marketplace and your income is between $12,060 and $31,050 ($20,420 to $51,050 for a family of three), you can also qualify for help with cost sharing. Special modified silver plans are available with lower deductibles, copays, and annual out-of-pocket limits on cost sharing.

WHAT TO EXPECT AT OPEN ENROLLMENT

If your current plan continues to offer coverage in 2018, you may choose to remain in that plan. And if you do nothing, you might be automatically renewed into that plan for 2018. If your plan is no longer offered in 2018, the marketplace will automatically enroll you in a different plan, unless you select a new plan for yourself. It is wise to review all your 2018 plan choices during open enrollment because different options may be offered. In addition, it is important to update your marketplace application to ensure you get the maximum financial help that you are eligible for.

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-reform-frequently-asked-questions/

The Henry J. Kaiser Family Foundation Headquarters: 2400 Sand Hill Road, Menlo Park, CA 94025 | Phone 650-854-9400
Washington Offices and Barbara Jordan Conference Center: 1330 G Street, NW, Washington, DC 20005 | Phone 202-347-5270

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Filling the need for trusted information on national health issues, the Kaiser Family Foundation is a nonprofit organization based in Menlo Park, California.