What Patients Should Know about ACA Marketplace Enrollment During COVID-19

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Whether you’re covered by a private employer-based plan or the ACA Marketplace, open enrollment periods typically fall between November and December each year, and they give you an opportunity to change health plans for any reason. While most of the ACA Marketplace enrollment rules and deadlines remain the same as previous years, COVID-19 has stirred up much confusion for anything health coverage-related. And because many Americans have experienced either economic or medical hardship due to COVID-19, it’s important to understand updates to coverage requirements and Special Enrollment periods in light of the pandemic.

Open Enrollment Period Dates & Information

In order to change your health plan outside of an open enrollment period, a qualifying life event must have occurred, such as termination of coverage due to job loss. While different states and private, employer-based insurance plans have their own set of rules for open enrollment, any plan offered as part of the ACA Health Insurance Marketplace - or Exchange - must at minimum adhere to certain federal standards for open enrollment and special enrollment periods.

If you would like to enroll in coverage that begins on January 1, 2021 on a Marketplace plan, you can do so between Sunday, November 1, 2020 until Tuesday, December 15, 2020. This window for changing coverage applies to everyone, regardless of whether you want to switch plans or if you recently lost coverage. If you miss this period, however, you will most likely be unable to enroll on the Exchange for 2021 unless you experience a qualifying life event.

Special Enrollment Periods & How COVID-19 Affects Qualifying Life Events

If you would like to enroll in coverage that begins before January 1, 2021, or if you miss the Open Enrollment period, you may be able to still receive coverage on the Marketplace through a Special Enrollment Period. In order to qualify, you will need to have experienced a qualifying life event, such as getting married, having a baby, involuntary loss of coverage, or a change in residence. Find a full list of qualifying events and their requirements here.

Prior to the pandemic, enrolling in a new plan must have occurred no more than 60 days after experiencing the qualifying life event. However, because FEMA declared COVID-19 a national emergency, the 60-day window does not apply if you couldn’t enroll in coverage due to COVID-19. This exemption applies only if the life event event (i.e., job loss) occurred on or after January 1, 2020.

If you were furloughed, you may qualify for the Special Enrollment period if your health coverage was affected, and you may also be eligible for a premium tax credit to help with coverage expenses as well. You are also entitled to the Special Enrollment period even if you are eligible for COBRA coverage but do not enroll. Even if you enroll in COBRA, you may also qualify for the Special Enrollment Period if your previous employer no longer contributes and your cost share changes.

COVID-19 Relief as Income

The total subsidy amount you receive towards your premium depends mostly on a modified adjusted gross income developed by the ACA. If you received the economic payments by the IRS as part of the CARES Act (up to $1,200 per taxpayer), you do not have to include this in the reported income on your application. However, if you received an additional $600/week as part of the extended employment benefits that the CARES Act allotted, that will be taken into account when determining subsidy eligibility. It will not be considered for decisions concerning Medicaid eligibility.

ACA Marketplace Coverage of Coronavirus

The Families First Coronavirus Response Act mandates that almost all private health plans, as well as Medicare and Medicaid, pay for COVID-19 testing and cannot require prior authorizations or cost sharing during the emergency. Short-term health plans and others that do not offer minimum essential coverage are exempt from the bill, but some states have implemented their own requirements that require full coverage for testing as well. However, there are no federal regulations that prohibit cost-sharing for the treatment of COVID-19, which can still be subject to deductibles, copays, etc.

How to Apply for Coverage By State

Most states use HealthCare.gov as the exchange website where individuals can apply and enroll in the Marketplace health plans. However, about 14 states, as well as Washington DC, use their own websites, such as California, Pennsylvania and New York. You can find the full list here.

Tips on Talking with Patients about Open Enrollment

If your patient is planning to enroll in a new plan, make sure they understand whether you will remain in-network and/or a preferred provider. It’s also important they understand the differences in plan terms, such as deductible, maximum out-of-pocket and coinsurance, but be sure you do not advise them which plan to buy. You may also want to create a checklist of questions patients should ask their potential carrier, such as if they are a part of the ACA Marketplace, when coverage begins and cost sharing requirements for treatments or medications they currently receive.

For more information on Open enrollment and special enrollment periods for ACA Marketplace plans, learn more here.

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