It’s Open Enrollment Day!

Today is the official opening day of the open enrollment period for anyone needing health insurance in 2022. This open enrollment period on the Marketplace (aka the Exchange aka healthcare.gov) will end on January 15, 2022 so if you need health insurance, you’ve got two and a half months to enroll. However, if you need coverage by January 1, 2022, you’ll need to enroll by December 15, 2021 to make sure you’re all set for the New Year. [And of course, if you lose coverage, move, get married, have a baby, or adopt a child, you’ll qualify for a special enrollment period outside of open enrollment.] Before you go any further, make sure you brush up on all the health insurance terms you need to know!

Who can get insurance on the Marketplace?

If you live in the U.S. and are a citizen or lawfully present, you can enroll in a Marketplace plan. Of course, a majority of people already have insurance through their employer (almost 50%), followed by Medicaid (19.8%) and Medicare (14.2%) but recent estimates still put the adult uninsured rate at 9.2%, or 30 million people. In 2019, nearly 74% of uninsured adults reported they did not have insurance due to the prohibitively high cost and did not have access to coverage through a job. In the 12 states that did not expand Medicaid, there are 2.2 million adults that fall in the gap between Medicaid eligibility and financial assistance on the Marketplace. The Biden Administration launched a special six-month enrollment period in February, during which 2.8 million people signed up for coverage. In total, over 12 million Americans have coverage through the Marketplace. Medicaid also enrolled upwards of 10 million individuals during the pandemic.

This enrollment period, there will be enhanced premium subsidies thanks to the American Rescue Plan, a longer period to shop, and four times as many Navigators as last year to help consumers. A report from the Centers for Medicare and Medicaid (CMS) estimates that the average monthly premium for a benchmark silver level plan will decline by 3% this year. This would be the fourth year in a row that premiums have dropped! The enhanced premium subsidies will have a dramatic effect on cost – four in five consumers will be able to find health care coverage for $10 or less per month thanks to those subsidies. Deductibles are also decreasing for bronze and gold plans.

What enhanced subsides are available?

• Silver plans with zero premium and vastly reduced deductibles for people up to 150% of the federal poverty level (FPL)
  Premium subsidies will increase for those up to 400% FPL, meaning less cost to consumers for coverage
• Premium subsidies are available for the first time to those above 400% FPL & will be required to contribute no more than 8.5% of household income to a benchmark plan
• These subsidies are only available for the calendar years 2021 and 2022 but there are ongoing negotiations in Congress to include them in the spending package and extend for an undetermined number of years

On the Marketplace, you’ll be prompted to enter information to help determine if you qualify for enhanced premium subsidies, no cost premiums, or Medicaid. If you are eligible for Medicaid in your state, you will be directed to sign up for Medicaid coverage rather than enroll in a Marketplace plan. Kentucky, Maine, and New Mexico are joining a handful of other states that run their own Marketplace – you’ll be directed there via healthcare.gov if you reside in one of those states. Everyone else uses the federally run website to find and purchase coverage. You can use the Kaiser Family Foundation premium assistance calculator to see if you might qualify for subsidies.

What if I need help enrolling?

There are 60 Navigator programs in the 30 federally-facilitated Marketplaces that received $80 million to help consumers understand their choices for coverage and complete their applications for financial assistance. Compared to last year, the Navigator budget increased by $10 million and the number of programs doubled. The Navigator programs have hired nearly 1.500 individual navigators to help consumers. There are also community organizations that are partnering with the Centers for Medicare and Medicaid for outreach and education about enrollment!

What is covered by a Marketplace plan?

All plans offered on the Marketplaces must cover the essential health benefits as outlined by the ACA and further determined by the Secretary of Health and Human Services. These benefits fall into ten categories: ambulatory patient services (outpatient care), emergency services, hospitalization, maternity and newborn care, mental health and substance use disorder care (including behavior health treatment), prescription drugs, rehabilitative and habilitative services, laboratory services, preventive and wellness services, and pediatric services (including oral and vision care). Prior to the ACA, more than 3 in 5 people lacked maternity coverage, 1 in 3 did not have substance use treatment, almost 10% lacked prescription coverage, and 1 in 5 did not have mental health coverage.

Why should I compare plans?

While every plan has to cover the EHBs as required by the ACA, there are differences in what you’ll pay for a monthly premium, annual deductible, whether you need a primary care doctor to refer you for specialty care (an HMO plan) or if you can seek specialty care yourself (a PPO plan), and cost-sharing like co-payments or co-insurance that you will owe for using services. A higher premium usually means a lower deductible (the amount of money you will pay for using services until the insurance plans covers everything) and vice versa. Young, healthy individuals usually choose a lower premium, higher deductible plan with the assumption that they will not use a significant amount of health care and just pay their premium and any small costs that come along. But if you have chronic medical conditions with unpredictable needs or are a high utilizer of health care, you might want a higher premium, lower deductible plan that will allow you to be more certain in your annual costs. Either way, this is why there are navigators available to help! Use them!

Some other important issues to know about:

• New rules around surprise billing will go into effect on January 1st. All insurance plans – including Marketplace plans – will be required to cover emergency services (excluding ground ambulances) at the in-network rate and any care provided at an out-of-network emergency room will be required to bill at the in-network cost sharing price for your plan. This change will also apply to non-emergency care at in-network facilities.
• There is no more “public charge” rule, which was implemented by the Trump Administration and would have made it harder for immigrants entering or living in the country to stay if they needed public assistance. In the case of health insurance, this was mostly applicable to people applying for Medicaid or CHIP and deterred an unknown number of people from applying for public insurance for fear of immigration action. Under current rules, immigration officials will not consider enrollment in Marketplace plans, CHIP, or Medicaid in the public charge test for green cards.
• Starting in 2022, healthcare.gov will have a special enrollment period every month for people with income up to 150% FPL ($19,320 per year for a single person in 2022, $32,940 for family of 3). Open enrollment is the best time to sign up but having these SEPs throughout the year will undoubtedly benefit millions.