ACA Open Enrollment Season: Answers to Consumer Frequently Asked Questions

1084630_question_mark_1Open Enrollment Season for federal and state exchanges offering insurance coverage in the “Health Insurance Marketplace” for 2016 began this month, and will run through January 31, 2016. During this period, individuals may newly enroll with, renew or change their health insurance plans or providers. In fact, more than 543,000 people have already obtained coverage in the Marketplace during the first week of open enrollment for 2016. Thirty-four percent of those were new consumers, per a report by the federal Centers for Medicare and Medicaid Services.

According to an article published by “Shots,” the online channel for health stories from the National Public Radio Science Desk, the occasion of Open Enrollment Season has prompted many consumer questions about details of enrollment and available marketplace plans, including the impact of high deductible plans; options in obtaining in- and out-of-network health services; and confronting cost increases in marketplace health plans.

Some guidance provided in response to consumer questions are as follows:

  • Most health plans are required to cover costs of preventive care with no out of pocket costs to consumers, even if the plan would otherwise require a deductible.
  • Even high deductible health plans commonly require consumer co-payments for certain services, such as prescription drugs, primary care visits and specialist visits. (The law caps consumer out-of-pocket costs at $6,850.)
  • The law does not require plans to offer out-of-network benefits. Plans simply must offer a network of health providers to give consumers broad access to health services without unreasonable delay.
  • Premiums in marketplace health plans are increasing 7.5 percent on average. Savvy consumers should compare plan offerings to save money on premiums.
  • Comparison shopping and switching plans saves consumers money. Consumers who switched plan types with the same providers between 2014 and 2015 saved nearly $400 annually in premium costs; and those who switched providers saved nearly $500 per year.

Of course, the Open Enrollment period deadlines do not apply to applicants for Medicaid or the Children’s Health Insurance Program (“CHIP”). Consumers may apply for coverage in those programs at any time.

Online guidance is also available from the federal government on the “” website. This resource provides a summary overview and detailed practical guidance concerning Affordable Care Act requirements for individuals and small businesses in obtaining insurance coverage. It also provides answers to frequent questions about these requirements. Guidance from this resource include:

  • The Health Insurance Marketplace is for people who don’t have health coverage. Consumers who have existing coverage through their employer plans could still opt to buy additional coverage in the Health Insurance Marketplace, but would pay full price for Marketplace coverage. Given that most employer plans do meet ACA coverage standards, covered employees need not obtain additional or substitute coverage in the marketplace. In addition, as explained on the website, consumers cannot use Marketplace coverage as an alternative or supplement to Medicare coverage.
  • Cost of Marketplace coverage depends on the consumer’s estimated income for 2016, not the individual’s actual income in 2015. Additionally, there are ways suggested for consumers to save money in purchasing Marketplace plans. These include a premium tax credit to lower the monthly insurance bill, as well as savings on out-of-pocket costs such as deductibles and co-payments.
  • Consumers can apply for coverage in four ways: online, by phone, with in-person help, or using a paper application.

Small business owners (those with 50 or fewer full-time employees) may also obtain guidance from The site details the Small Business Health Options Program (SHOP) Marketplace, providing access for small businesses to provide health and dental insurance policies to employees. Open Enrollment Season deadlines do not apply to small businesses: They are able to begin offering SHOP coverage to employees at any time of year.

If you have questions about this post, contact our Georgia business and healthcare law firm at (404) 685-1662 (Atlanta), (706) 722-7886 (Augusta) or

Disclaimer: Thoughts shared here do not constitute legal advice. Please consult with an attorney to discuss your legal issue.

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