If you’re shopping for healthcare on the exchanges, this guide can help.

By Brienne Walsh
November 09, 2020
Credit: Getty Images

The Affordable Care Act, passed by President Barack Obama in 2010, transformed health care in the United States. Thanks to the ACA, roughly 20 million people gained coverage, according to estimates from the Kaiser Family Foundation. But even after the passage of the ACA, millions are uninsured, and many cite a lack of affordability as the main reason they don’t have health insurance. 

Whatever your feelings on the ACA, it’s likely even more people will at least be considering getting their coverage through the federal Health Insurance Marketplace or state exchanges. The reason: An estimated 14.6 million Americans have lost employer-provided health insurance due to the pandemic.

The open enrollment period for 2021 health insurance on the federal Marketplace opened on November 1. Below, we provide you with the ten things you need to know whether you’re a new or returning customer to the marketplace.

1. The enrollment period ends December 15 in most, but not all, states. The Affordable Care Act allows for states to establish their own marketplaces (also called exchanges), thereby allowing them more flexibility with enrollment periods. For the upcoming year, 36 states are using the federal marketplace, which is accessible through healthcare.gov, and has a firm deadline for enrollment of December 15. Fourteen states, as well as the District of Columbia, have their own marketplaces for 2021. Of these states, California, Colorado and the District of Columbia have permanently extended open enrollment, and seven of them—Massachusetts, Minnesota, New York, Nevada, Pennsylvania, Rhode Island and New Jersey—have extended enrollment for 2021 coverage. To check what the enrollment period is for your state, follow this link. 

On a side note, if you live in an area recently affected by a natural disaster, such as a wildfire or hurricane, or have been affected by COVID-19 illness in your family, you may qualify for a special enrollment period.

2. Some of you may have more choices in 2021. The health insurance marketplace is a bit like musical chairs, notes Karen Pollitz, a senior fellow at the Henry J. Kaiser Family Foundation. This year, there are a few more chairs in the game. Major providers like UnitedHealth Group, which dropped out of most exchanges funded by the Affordable Care Act in 2017, have decided to return to the marketplace. “Insurers have learned that [participating in the healthcare exchange] can actually be profitable,” says Pollitz. “This makes [for] more choices for consumers.”

3. Premiums in many states have gone down. Premiums for plans usually go up every year, notes Pollitz. For 2021, however, many states are reporting decreases in premiums. For example, Maine has reported a 13% drop in average premium prices, and Maryland has reported a 12% drop. One potential reason is that some states have enrolled in reinsurance programs, which allow a third-party entity to pay part of an insurance company’s claims once they have surpassed a certain amount. To estimate the potential cost of your own health insurance premiums, use the Kaiser Family Foundation’s Marketplace calculator.

4. Look into whether you qualify for Medicaid. Even if you recently earned six figures, but were laid off and are currently collecting unemployment, you may very well qualify for Medicaid, which pays almost all costs for medical expenses; if you have children, they could qualify for the Children’s Health Insurance Program (CHIP) even if you have too much income to get Medicaid. “It doesn’t matter what you used to earn,” says Pollitz. “It matters what you earn now.” 

Eligibility, like many things having to do with healthcare, is affected by where you live. Currently, 38 states and the District of Columbia have expanded Medicaid coverage under the Affordable Care Act to include coverage for adults and children living within 133% of the federal poverty level—currently $26,200 for a family of four. Twelve states including Georgia, Kansas, Florida and Mississippi have not adopted expanded coverage, and have more limited options. To learn about where your state stands, follow this link.

5. You may qualify for federal subsidies. The Affordable Care Act provides for two types of subsidies for families or individuals that don’t qualify for Medicaid—premium tax credits and cost-sharing reductions. In order to receive a premium tax credit in 2021, individuals must make between $12,760 and $51,040, and a family of four must make between $26,200 and $104,800. Cost-sharing reductions lower maximum out-of-pocket costs, which otherwise can be up to $8,550 for an individual and $17,100 for two or more people in 2021. With subsidies, a recent survey by the nonprofit Get America Covered found that 75% of Healthcare.gov users could find a plan with a premium of $50 or less per month.

6. Choose a broker wisely. If you feel overwhelmed by all of this information, you’re not alone. Nearly one in five Americans who enrolled in the Affordable Care Act in 2020 did so with the help of a navigator or broker. Working with one of these individuals or companies is generally free. Navigators, also called assisters, are impartial about which plan you choose because they’re funded by government grants. Brokers are paid by commission, so be cautious if they seem to promote certain plans over others, especially if they cold-called you or interact exclusively online. In fact, one in four marketplace enrollees reported that they were offered a non-ACA compliant policy by a broker or commercial health plan representative.

“My general rule of thumb is to choose someone local who serves the community,” says Sabrina Corlette, a research professor at the Center on Health Insurance Reforms at Georgetown University. “You’re less likely to get scammed by someone who knows they can run into you.” 

To find assistance near you, use healthcare.gov’s locator. The Marketplace Call Center (1-800-318-2596) also has representatives standing by who can walk you through the application process.

7. Don’t wait until the last two weeks to enroll. Applying for healthcare through the exchange can be time consuming—and navigators get booked up fast. In fact, 12% of people who applied for healthcare in 2020 tried to get assistance, but never found it. “Every year I tell people, don’t wait until the last minute,” says Pollitz. “Start the application as soon as possible in case you need help.”

8. Watch out for scams. Corlette noted that in the past few years, there has been a proliferation of deceptive healthcare products on the market. “They walk and talk like traditional health insurance, but they are anything but,” she notes. Enrolling in one could mean that you pay lower premiums than for an ACA plan, but in actuality, have very little coverage in the case of an emergency or serious illness.

The best way to vet a plan, Corlette notes, is to always start your search on healthcare.gov—as opposed to a search engine like Google. “Any health plan on healthcare.gov has passed muster already,” she notes.

9.  Don’t rely on auto-renewal. In most states, if you’re already enrolled in a plan, and don’t do anything to change your enrollment, the state will automatically renew your health coverage at the next year’s rate. Relying on this is a mistake because the marketplace is constantly changing, experts say. When new insurers enter the realm, it leads to competition that can lower both your premiums and the tax subsidy you can receive, potentially leaving you to pay more for the same plan. “Even if you know that you want to keep your plan for 2021, log into your account and check to see what your cost for 2021 would be,” recommends Pollitz. “It’s very important to actively renew.”

10. Even if you’re worried about challenges to the ACA, still consider applying for coverage in 2021. The Supreme Court is scheduled to hear California v. Texas, a case that questions the legitimacy of the ACA, in November. But you should still apply for coverage for 2021 if you need it. “When you sign up, your insurance company signs a one-year contract with you,” notes Corlette. “It’s not easy for them to drop you.” Plus, she adds, that until the Supreme Court renders a decision, which is not expected until Spring 2021, the ACA remains the law.

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