Here’s what you need to know about open enrollment for individual and family health coverage.

What & When is the ACA Open Enrollement?

The Affordable Care Act open enrollment is the window each year during which people can compare all the different health plans that are available and select the one that fits their needs best for the coming year.

The open enrollment period typically runs November 1 through January 15, but the dates do vary a little in states that run their own exchanges.

Suggested Read:

What states do not end open enrollment on January 15?

There are 20 (as of plan year 2025) fully State-based exchanges, or SBEs.  All of these states have the option to set their own enrollment deadline, as long as it is not earlier than December 15. 

Most of the SBEs stick with the federal window of November 1 through January 15.  However, 7 SBEs have chosen to change their enrollment deadline.

  • California: January 31
  • District of Columbia: January 31
  • Idaho: December 15
  • Massachusetts: January 23
  • New Jersey: January 31
  • New York: January 31
  • Rhode Island: January 31

Idaho is the only SBE where enrollment ends in December.  With changes to CMS rules that take affect in 2025, the enrollment window for Idaho’s SBE will need to change.

Can't I just get a plan in the middle of the year?

Not usually, no.  You may be eligible to purchase a new plan or change your current plan if you qualify for a Special Enrollment Period, or SEP.

How do I enroll in a Marketplace plan?

During open enrollment, you’ll need to go through the Marketplace in your state.  There are also sites such as this that allow you to view plans from one online portal no matter what state you live in.  Here you will be able to see all of the plans offered in your area and compare them side by side using the Summary of Benefits.

Make sure to read through our What to Ask When Buying Health Insurance before you start shopping so that you have a better idea of what it is you’re looking for in a plan.  If it’s your first time looking into health insurance on your own, our First Time Buyers Guide is a good place to start as well.

You can also go through a broker or an agent (like us) to help you find and enroll in a plan.  Unless you’re an expert in all things health insurance, using a broker is usually a better option as there isn’t any cost to you.

No matter the route that you go, you’ll need a few things completed on your end first.

  • Do you have certain doctors that you want to use?
  • Do you take any medications?  What are the out of pocket cost for these medications between plans?
  • How much do you want to spend out of pocket when you need care compared to each month in premiums?

Here is what each person being added to the plan will need:

  • Name, address, birth date, and social security number.
  • Payment information for the first month’s premium.
  • If you are over 30 and you want a Catastrophic plan, you need a hardship exemption.
  • Have you income information on hand.  You will need to enter your household AGI to see what subsidies you qualify for.

You will not need to answer any medical questions, and make sure that the plans you are looking at has your medical providers in-network and covers your medications.

A broker can assist you with all of this.

After you have completed the process, log out and log back into your Marketplace account to ensure that everything is in order.

Make sure to watch for emails and mail from the Marketplace as you may need to verify income or provide residency documentations.

Once your policy and ID cards arrive in the mail, read through all of and reach out to us if you have any questions.

Do I need to do anything if I want the same plan for next year?

In my opinion, you should at least review your coverage each fall and making sure it still works for you.

Auto-renewal or automatic re-enrollment for the coming year’s coverage is available, but it may not be in your best interest to rely on this.  Selecting your own plan for the coming year is better than auto-renewal.

Make sure to pay close attention to any notices you receive from your health plan, as they will let you know how your plan may be changing for the following year.

What changes are there for 2025 ACA plans?

CMS, the agency in charge of regulating most types of health insurance, has released it’s final rules that make changes to ACA Marketplace.  Most of these changes will be in effect for the 2025 plan year, but some of the more compex changes will be phased in through 2027.

Dental Care for Adults

Every year, states select a benchmark plan that outlines what the minimum coverage pan must provide in that state.  By default, the plan must meet the ACA’s definition of minimum essential coverage, but states are allowed to require a more strict plan.

Issues arise when health plans went beyond the state’s benchmark plan because the extra services could be seen as non-essential.  When a service is considered non-essential, cost-sharing protections do not apply, and patients pay more out of pocket for their services.

The new rule allows states to label dental coverage for adults as an essential health benefit as part of that state’s benchmark plan without running into the issue of effecting the consumer’s CSR.

Prescription Drugs

Similar to dental coverage, plans can now include prescriptions that go beyond the state’s benchmark plan without those medications being labeled as non-essential.

This means that if a plan includes a prescription that goes beyond the benchmark, they are considered essential and will be covered.

Changes in Plan Presentation

CMS made some technical change to how health plans are marketed so that consumers have an easier time picking the right plan for themselves.  This is consistent with the standardized changes made over the past coupe of years; standardization means fewer options and variables for consumers to consider, which makes it easier for individuals and families to find the best-suited plan.

There are also new lower-cost plans tailored to people with certain chronic conditions that states can choose to offer.

Changes to how SBEs Operate

The new law requires states that wish to host their own SBE first have a full year of operation on the federal platform.  This will make sure that the state is prepared and will avoid potential issues.

SBEs will also be required to host a ‘Healtcare.gov-type’ enrollment system where eligibility can be checked.

SBEs are required to have their open enrollment period extend for a minimum of 11 weeks.  When the period starts and ends can vary based on state, but the duration must meet the 11 week requirement.

Changes to short-term health insurance

The new rules reduce total duration of short-term health plans to 4 months.  This change is part of the No Surprises Act.

DACA recipient eligibility

2025 is the first year that DACA recipients will be eligible to use the Marketplace for the first time.

Making it easier to enroll in coverage

The new rules extend the SEP for consumers with incomes below 150% of the federal poverty level (FLP), allowing them to enroll in coverage in any month rather than only during Open Enrollment.

Open Enrollment FAQ

Who can use the Marketplace?

To enroll in a Marketplace plan;

  • You must live in the United States
  • You must be a US citizen or national or be lawfully present
  • You can not be incarcerated
  • You can not be enrolled in Medicare
Who can receive financial assistance?

Income-based subsidies are available for people that are not eligible for Medicaid or employer-based coverage, but also make below a certain amount each year.

Subsidies available can be used to help reduce monthly premiums or cost-sharing amounts. 

Will I be penalized if I don't have insurance?

Maybe.  The federal mandate that penalized people for not having insurance has been removed, but a few states still impose their own penalties on people without coverage. 

Those states include:

  • Massachusetts
  • New Jersey
  • California
  • Rhode Island
  • District of Columbia
Where can i find help enrolling in a Marketplace plan.

We are always willing to help.  Give us a call and we can talk.

Additionally, your state's marketplace has a list of numbers that can be called to talk with someone who can help you, but these people are not allowed to make recommendations for you nor can they work with people on Medicaid.

Will I be asked health questions?

No.  You will be asked if you use tobacco though.

Am I guaranteed to be accepted to a plan?

Yes.  You can not be denied coverage of a pan offered on the Marketplace.

What do Marketplace plans cover?

All ACA plans are considered MEC and offer the essential health benefits.

States have the option to require more benefits be added to this list if they choose.

How can I find out if my doctor is in a health plan's netowrk?

Each plan sold on the Marketplace must provide a link to its health provider directory so that consumers can find out if their health providers are included.

This network information may not always tell you if that provider is accepting new patients, or if a provider speaks your language. 

Will I be charged more based on my age?

Yes, in most states.  Federal rules allow companies to charge older adults (in their 60s) up to 3 times the amount they charge younger adults (in their 20s).

What if I don't have a checking account?

Plans are required to offer multiple payment methods and cannot require you to pay by automatic bank withdrawal.

Federal rules require companies to accept paper checks, cashier's checks, money orders, pre-paid debit cards, and EFT.  All of these methods need to be available for both the initial premium and all ongoing payments.

Aaron

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