Plans on the Exchange
Understanding Health Reform
OPEN ENROLLMENT IS NOW CLOSED FOR 2019.
You can now only enroll in a qualified health insurance plan if you qualify for a "Special Enrollment Period".
Changes that qualify for a Special Enrollment Period:
Loss of health coverage
You may qualify for a Special Enrollment Period if you or anyone in your household lost qualifying health coverage in the past 60 days OR expects to lose coverage in the next 60 days. Coverage losses that may qualify you for a Special Enrollment Period:
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Losing job-based coverage
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Losing Individual health coverage for a plan or policy you bought yourself
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Losing eligiblity for Medicaid or CHIP
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Losing eligiblity for Medicare
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Losing coverage through a family member
Changes in household size
You may qualify for a Special Enrollment Period if you or anyone in your household in the past 60 days:
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Got married. Pick a plan by the last day of the month and your coverage can start the first day of the next month.
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Had a baby, adopted a child, or placed a child for foster care. Your coverage can start the day of the event — even if you enroll in the plan up to 60 days afterward.
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Got divorced or legally separated and lost health insurance. Note: Divorce or legal separation without losing coverage doesn’t qualify you for a Special Enrollment Period.
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Death. You’ll be eligible for a Special Enrollment Period if someone on your Marketplace plan dies and as a result you’re no longer eligible for your current health plan.
Changes in residence
Household moves that qualify you for a Special Enrollment Period:
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Moving to a new home in a new ZIP code or county
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Moving to the U.S. from a foreign country or United States territory
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A student moving to or from the place they attend school
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A seasonal worker moving to or from the place they both live and work
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Moving to or from a shelter or other transitional housing
Note: Moving only for medical treatment or staying somewhere for vacation doesn’t qualify you for an SEP.
Important: Starting July 2016, you must prove you had qualifying health coverage for one or more days during the 60 days before your move. You don’t need to provide proof if you’re moving from a foreign country or United States territory.
More qualifying changes
Other life circumstances that may qualify you for a Special Enrollment Period:
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Changes that make you no longer eligible for Medicaid or the Children’s Health Insurance Program (CHIP)
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Being a member in a federally recognized tribe or having status as an Alaska Native Claims Settlement Act (ANCSA) Corporation shareholder
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Becoming newly eligible for Marketplace coverage because you’ve become a U.S. citizen, U.S. national, or lawfully present individual
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Becoming newly eligible for Marketplace coverage because you’ve been released from incarceration (detention, jail or prison)
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AmeriCorps members starting or ending their service
*** Additional Informaiton:
How are plans categorized?
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Plan tiers are categorized by “actuarial value”.
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Actuarial value is a measure of expected medical costs a health plan will cover for a standard population.
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For example, the gold plan has an actuarial value of 80%. That means for the standard population the plan will pay 80% of their health expenses and the enrollee will pay 20% through a combination of deductibles, copays and coinsurance
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What is actuarial value?
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Catastrophic Plans are lower-cost with limited benefits for people under 30 or people with financial hardship.
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Everyone must have Minimal Essential Coverage
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Minimum Value Test
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The plan meets the 60% coverage requirement with respect to the total allowed costs of benefits
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High deductible plans are no longer permitted
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Deductibles cannot exceed:
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$2,000 for self-only
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$4,000 for family
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True out-of-pocket maximum: limits what enrollee pays for coinsurance, deductibles and copayments for the year
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Capped at maximum on HDHP plans: $6,250/self-only and $12,500 family for 2013.
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Out-of-network services do not count toward maximum.
