The Affordable Care Act (ACA) provided that health coverage by the insurance plans offered in the State Insurance Exchanges and coverage for new beneficiaries under the Medicaid Expansion provision would take effect by January 2014.
In most states, enrollment of individuals without insurance coverage in these programs begins on October 1, 2013.
The law contained a number of provisions that would help streamline and assist patient enrollment efforts in these programs.
Important Enrollment Dates
There are 3 key dates important to new patients and to providers:
October 1, 2013: Exchange/Marketplace open enrollment starts
January 1, 2014: Health coverage can start
March 31, 2014: Open enrollment ends
Open Enrollment in the Exchanges
The period of time during which individuals who are eligible to enroll in a Qualified Health Plan can enroll in a plan in the Marketplace. For 2014, the Open Enrollment Period is October 1, 2013–March 31, 2014. For 2015 and later years, the Open Enrollment Period is October 15 to December 7 of the previous year.
Individuals may also qualify for “Special Enrollment Periods” outside of Open Enrollment if they experience certain events. These “Qualifying Life Events” include, but are not limited to, moving to a new state, changes in income, and changes in family size (for example, a marriage, divorce, birth, or pregnancy).
Enrollment in Medicaid
Patients who qualify for Medicaid or the Children’s Health Insurance Program (CHIP) will be able to learn about their eligibility for these programs in the Exchanges.
Coverage under these programs begins immediately. There is no enrollment period for these programs.
The ACA simplifies Medicaid enrollment in states that take up the Medicaid expansion, making all individuals with income up to 138% of the federal poverty level eligible for the program. In states that have not taken up the Expansion, the program is only open to certain populations and has varied income qualifications.
The ACA sets out a consumer-friendly approach to patient enrollment in the new programs – an approach referred to as “no wrong door.”
Patients will be able to utilize a “single-form application” to that will determine which programs, and what types of assistance, they are eligible for.
Eligibility will be determined through a formula called Modified Adjusted Gross Income (MAGI). MAGI is based on the Internal Revenue Service (IRS) definition of adjusted gross income.
Applicants will be able to apply through online, by phone, and through in-person enrollment.
Applicants may apply through either the Insurance Exchange or through their state Medicaid program. The application will be able to identify eligibility for either Medicaid or for Qualified Health Plan coverage, and premium tax credits.
To help consumers understand their new options and to apply for and enroll in appropriate coverage, the ACA includes a number of consumer assistance programs, including Patient Navigators, In-Person Assisters, and certified Application Counselors.
Some of these programs offer funding for training of personnel to perform these positions. HIV providers should consider how these roles may be incorporated into their practices.
Community Health Centers also receive federal funding to provide in-person enrollment assistance.