Open Enrollment: Public Vs Private Insurance Options

Open enrollment is a set period each year when you can buy health insurance or change your health insurance plan. It usually takes place between November 1 and mid-January. During this time, you can enroll in, renew, or change health plans through the Marketplace for the coming year. Open enrollment is applicable to both employer-sponsored plans and individual/family plans purchased directly from a health insurance company or through the Affordable Care Act (ACA) exchange (Marketplace). However, it's important to note that open enrollment doesn't apply to all types of insurance plans, such as short-term health insurance policies or limited benefit plans.

Open Enrollment Periods

The Affordable Care Act established the Open Enrollment Period to ensure everyone could get health insurance once a year. Before the Act, insurance companies could raise insurance premiums or refuse coverage based on medical history. Now, insurance companies cannot deny coverage due to someone's medical history or any pre-existing condition.

If you miss the Open Enrollment Period, you may have to wait until the next annual period to enrol or make changes to your plan. However, qualifying life events, such as getting married, having a baby, or losing coverage, can trigger a Special Enrollment Period, allowing for mid-year enrolments and plan changes. Additionally, some people, including Native Americans and those eligible for Medicaid or CHIP, can enrol in coverage at any time.

Special Enrollment Periods

Open enrollment allows people to sign up for health insurance outside of the yearly Open Enrollment Period. This applies to private insurance, and you may qualify for a Special Enrollment Period if you've experienced certain life events or fall below a minimum income threshold.

• Changes in household: Getting married, having a baby, adopting a child, getting divorced, or experiencing the death of a family member can all qualify you for a SEP. You may also qualify if you lose health coverage through a family member, such as when you turn 26 and can no longer be on a parent's plan.
• Changes in residence: Moving to a new address, including moving to a new ZIP code or county, or moving to or from a place of education or work, can qualify you for a SEP. Moving for medical treatment or vacation is typically not considered a qualifying change.
• Loss of health coverage: Losing your health insurance, whether through an employer, family member, or as an individual, can trigger a SEP. This includes losing coverage due to discontinuation of a plan, ineligibility, or choosing not to renew. Voluntarily dropping coverage does not usually qualify, unless it is accompanied by a decrease in household income or a change that makes you eligible for savings on a Marketplace plan.
• Medicaid or Children's Health Insurance Program (CHIP) coverage: Losing Medicaid or CHIP coverage, or being denied coverage, can qualify you for a SEP. This includes losing coverage due to changes in household income or age restrictions.
• Eligibility for Medicare: Losing premium-free Medicare Part A can trigger a SEP. Losing Medicare Parts B or D only does not qualify.
• Other qualifying changes: Gaining membership in a federally recognised tribe, becoming a US citizen, leaving incarceration, or starting or ending service as an AmeriCorps member are all considered qualifying changes for a SEP.

The time frame for enrolling during a Special Enrollment Period can vary depending on the type of event. Typically, you will have 60 days before or after the event to enroll in a new plan. However, in the case of having a baby or adopting a child, your coverage can start from the day of the event, even if you enroll up to 60 days later.

Employer-Sponsored Plans

Open Enrollment is a set period during the year when you can buy health insurance or change your health insurance plan. It usually runs from November 1 to December 15, with some states offering longer enrollment periods.

For those with employer-sponsored health insurance, open enrollment periods are set by the employer. This type of insurance is usually the most common way for people to get health coverage before retirement age. It offers comprehensive coverage at affordable prices, as employers typically pay more than half of the healthcare costs.

The average annual premiums for employer-sponsored plans in 2020 were $7,470 for single coverage and $21,342 for family coverage. However, the average employee contributions are significantly lower, at $1,243 for single coverage and $5,588 for family coverage. This makes employer-sponsored insurance a cost-effective option for many.

Employer-sponsored health insurance often provides comprehensive benefits at more affordable prices than individual health plans. It is typically less expensive than individual health insurance unless the individual qualifies for tax credits.

There are different types of employer-sponsored plans, including Health Maintenance Organization (HMO) plans and Preferred Provider Organization (PPO) plans. HMO plans have limited networks, lower premiums, and more restrictions, while PPO plans are more flexible and offer a larger network of healthcare providers.

If you have access to employer-sponsored insurance, it is generally a good option to consider due to its affordability and comprehensive coverage. However, it is important to compare different plans and consider your specific health and financial needs when making a decision.

Individual/Family Market Plans

Open enrollment refers to a set period of time during the year when people can buy health insurance or change their health insurance plan. This period typically runs from November 1 to mid-December or mid-January in most states, though the exact dates vary. During this time, everyone has the chance to purchase private health insurance or change health insurance plans.

For Individual/Family Market Plans, open enrollment is an opportunity for individuals and families to purchase health insurance coverage directly, rather than obtaining it through an employer. This type of coverage is often referred to as coverage that people buy for themselves, as opposed to receiving it through their workplace.

The Individual/Family Market Plans are subject to the same open enrollment periods as other types of health insurance. In most states, the open enrollment period for these plans ends on January 15, though some states, like Idaho, opt for earlier deadlines. It's important to check the specific dates for your state.

During the open enrollment period, individuals and families can purchase ACA-compliant, Qualified Health Plans (QHPs) without complication. These plans are offered by commercial insurers and provide coverage for medical expenses such as doctor visits, hospital stays, prescription drugs, and preventive care.

If you miss the open enrollment period for Individual/Family Market Plans, there are still options available. Certain life events, such as losing job-based coverage, changing your household size, or gaining citizenship, may qualify you for a Special Enrollment Period (SEP) outside of the regular open enrollment window. During an SEP, you can shop for plans in the exchange or off-exchange, with potential access to premium subsidies and cost-sharing reductions.

Additionally, some states offer alternative programs with different deadlines, such as the Basic Health Programs in New York and Minnesota, the ConnectorCare program in Massachusetts, and the Covered Connecticut program. These programs may provide opportunities for enrollment outside of the standard open enrollment period.

It's important to note that most health plans sold outside of open enrollment don't count as qualifying health coverage, and there may be limitations on the availability of certain types of coverage.

ACA-Compliant Plans

Open enrollment is a set period during the year when you can buy or change your health insurance plan. The introduction of open enrollment was one of the major changes under the Affordable Care Act (aka Obamacare). During this period, you can buy Marketplace health insurance or change your health insurance plan. In most states, open enrollment runs from November 1 to January 15. However, some state-run exchanges have different schedules. For example, open enrollment in Idaho traditionally begins on October 15, while in New York, it starts on November 16.

The Affordable Care Act made it illegal for insurance companies to deny coverage based on an individual's medical history or pre-existing conditions. To avoid a situation where people only get health insurance when they know they will need medical care, the Act established an Open Enrollment Period so that everyone can get health insurance once a year.

After open enrollment ends, you can only purchase coverage if you have a special enrollment period (SEP). A special enrollment period is triggered by a qualifying life event, such as getting married, having a baby, or losing coverage. A qualifying life event is a significant change that would make someone eligible to enroll outside of the Open Enrollment Period.

Frequently asked questions