The Affordable Care Act (ACA) provided that health insurance plans offered in the State Insurance Exchanges will be made available for new enrollment or changes during an open-enrollment season each year.
There are also special enrollment periods outside of the open enrollment period following certain life events that involve a change in family status (for example, marriage or birth of a child) or loss of other health coverage.
The law contained a number of provisions that would help streamline and assist patient enrollment efforts in these programs.
The first open enrollment under the ACA was an extended period (much longer than in subsequent years), which began on October 1, 2013 and ended on March 31, 2014.
Open enrollment for the 2015 coverage period is November 15, 2014 through February 15, 2015.
Because this is an extended open enrollment period, coverage under a plan begins on the first day of the month following enrollment.
If a person enrolls:
Open enrollment for 2016 and beyond runs from October 15th through December 7th, with coverage starting on January 1st of the following year.
For example, for health insurance coverage starting January 1, 2018, individuals must sign up for that coverage between October 15, 2017 and December 7, 2017.
Individuals may also qualify for “Special Enrollment Periods” outside of Open Enrollment if they experience certain events, called “Qualifying Life Events.”
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).
The ACA sets out a consumer-friendly approach to patient enrollment in the new programs – an approach referred to as “no wrong door.”
How to Apply
Patients are able to utilize a “single-form application” to that will determine which programs, and what types of assistance, they are eligible for.
Where to Apply
Applicants are 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.
Assistance in Applying
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.
Learn More: Patient Navigators, In-Person Assisters, and Certified Application Counselors
Community Health Centers also receive federal funding to provide in-person enrollment assistance.
Eligibility for both the Exchanges and Medicaid 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.
Under the ACA, individuals are required to obtain insurance coverage beginning in 2014 or face tax penalties. This includes both adults and children who are legal US citizens. This provision is often referred to as the “Individual Mandate.”
Qualified Health Plans in the Exchanges have requirements for value and pricing that is structured into categories named after metals: the “bronze,” “silver,” “gold,” and “platinum” level plans. Each of these plans has different values within its category, and offers different prices and benefits to consumers.
Learn More: Plan Premiums and Pricing
Tax Credits are available to individuals of low- to middle-income levels who are purchasing insurance in the Exchanges. These credits take the form of subsidies which are applied to the plan premium (or “premium subsidies”).
Learn More: Tax Credits (Premium Subsidies)
Issue Brief: Outreach and Enrollment Within HIV/AIDS Programs – NASTAD
Tools for HIV Service Providers: Tools for the Ryan White Community – HRSA HIV/AIDS Bureau
Four Step Guide to Planning a Health Care Enrollment Event – The Partnership Center
Consumer Assistance in Health Reform – Kaiser Family Foundation
Special Enrollment Period – Healthcare.gov
Qualifying Life Events – Healthcare.gov
HEALTH REFORM ISSUE BRIEF – OUTREACH, ELIGIBILITY AND ENROLLMENT – NASTAD