Open Enrollment for Marketplace Health Plans Has Started: Things You Need to Know

Sign-up for the Affordable Healthcare Act Marketplace insurance started Nov. 1st and runs through January 15th. However if you need your insurance to start on January 1st, you must enroll prior to December 15th. 

Surprisingly, many people think that marketplace insurance is only for people who cannot afford insurance. This is untrue. Infact, the eligibility rules are quite lenient. To be eligible you must live in the United States, be a U.S. citizen or national and cannot be incarcerated. Also, if you have Medicare you are ineligible to buy a medical or a dental plan.

There are 5 changes for the 2023 that you need to be aware of:

Many people get insurance through their employer plans which may also be in the mist of open enrollment. Employees also need to be aware of the changes and make their selections accordingly because they can be affected by these new rules.

1.  If you are one of the people or families that did not qualify for the subsidies, you may now qualify. The “family glitch” has been addressed. The new rules expands the number of families with job based insurance who can choose to forgo their coverage at work and qualify for subsidies to get an Affordable Care Act (ACA) plan instead. 

Before, employees could qualify for a subsidy for marketplace insurance only if the cost of their employer-based coverage was too costly and unaffordable based on the threshold set each year by the IRS. However the determination took into account only how much an employee  would pay for insurance for him or herself. Adding family member costs was never part of the calculator therefore family coverage is often far more expensive than employee-only coverage. Subsequently, many employee’s families would go uninsured or pay more through their jobs for coverage than they might if they were able to get an ACA subsidy. The new rules state that eligibility for the subsidy must also consider the cost of family coverage. Now families can make a choice by doing plan and cost comparisons and making the best choice for them. If their share of the premium for tier employer-based coverage exceeds 9.12% of their expected 2023 income they can qualify for a subsidy. 

Now there will be two calculations.

• The cost of the employee only coverage as a percentage of the worker's income and
• The cost of adding family members

Sometimes employees can stay on the employer's plan while family members may be able to get a subsidized ACA plan.Because these moves might be challenged in court, however, if you could benefit, go ahead  and enroll.

2.  Preventative care will still be covered without a copay, but abortion coverage will vary

We all know that the abortion subject is an ever changing landscape. Those of you of childbearing age, keep that in mind.

Fortunately in the ACA there are cost sharing provisions for a range of preventative services for certain tests, vaccines, and drugs. The future of these provisions is in flux and may change.  It is possible that patients may have to pay the cost of cancer screenings or drugs that prevent the transmission of HIV. 

3.  Be aware that premiums are going up but fortunately most people on ACA plans will not be affected

You wouldn’t be surprised that premiums rates are rising for both ACA plans as well as employer coverage. Most people that get subsidies for ACA coverage will not feel that increase. The subsidies in the passage of the Inflation Reduction Act guaranteed that the enhanced subsidies that many Americans have received under legislation tied to the  pandemic will remain in place.

Remember there are income levels that will determine if you qualify for subsidies. People who earn up to 150% of the federal poverty level  - $20,385 for an individual and $27,465 for a couple - can get an ACA plan without a monthly premium. Those who earn up to 400% of the FPL –$54,360 for an individual and $73,240 for a couple will get sliding scale subsidies to help offset premium costs. People with incomes more than 400% of the FPL are required to pay no more than 8.5% of their household income toward premiums.

People who are covered through employer plans understand that the employer generally sets the amount workers must pay toward their coverage.  Some employees may realize higher premiums as their employers pass along the price hikes, resulting in higher deductibles or changing health care benefits. However, anyone whose employer premium coverage cost exceeds 9.12% of their income can check to see whether they qualify for a subsidized ACA plan

4. Debts to insurers or the IRS will not stop coverage

Traditionally people must prove to the government on their next tax filing that they received the correct subsidy, based on the income they actually received. Failure to do so would result in them losing eligibility for the subsidy the next time they enroll. However, due to a backlog in IRA tax filings consumers will get another reprieve for this enrollment period.  

Insurers can no longer deny coverage to people or employers who owe past-due premiums for their 2022 coverage. And current premium payments must be applied to current coverage not to previous plan coverage.

5. Comparison shopping should be easier

Traditionally coverage and cost can vary in premium amounts for office visits, and out-of-pocket costs. During this year’s open enrollment, new rules aimed at making comparison easier take effect. Now all ACA health insurers must offer a set of plans with specific standardized benefits.  Standard plans will have the same deductibles, copays, and other cost sharing requirements. These plans will also offer more coverage before a patient has to start paying toward a deductible.

These rules apply nationally to health plans sold on the federal marketplace. Any insurer offering nonstandard plans on the marketplace must now also offer the standardized plans as well. Starting Jan.1st, all health insurers must make available cost-comparison tools online or over the phone that can help patient predict their costs for 500 “shoppable services.” 

I am astounded every year how many people really don’t understand who can apply and qualify for ACA. Many people seem to think it is only for those who have very low incomes. This isn’t the case. Review these changes even if you have coverage through your employer. This may be a way to get the same or better coverage for your needs as well as a way to save some money on your healthcare costs. Take all of this into consideration including:

• If you will be seeing a specialist out of network
• Review your medication coverage, testing coverage and treatment coverage
• Reivew coverage for Stem cell transplants as well as CAR-T if those could be possible options for you this year.

The more you know about your treatment the better you can make legitimate plan comparisons and make the choice that's right for you and your family.

Diahanna is the Financial Program Director for the HealthTree Coach program.  She leads a team of Financial Coaches in providing support and resources to help others with the financial impact of myeloma.

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