When it comes to electing health care coverage, deadlines matter. Miss one, and you could find yourself facing thousands of dollars in medical bills down the road.
Starting Nov. 1 and ending Dec. 15 (in most states), uninsured Americans can sign up for coverage under the Affordable Care Act or renew the coverage they already have.
If you want coverage in 2021, you must enroll during these 45 days unless you later have a qualifying life event, such as getting married or divorced.
Some younger and healthier people may not think coverage is worth the monthly premiums.
But think again, says Gerald Kominski, a professor of health policy and management at UCLA.
“There’s the idea that ‘I take care of myself, I live a healthy lifestyle, I eat well, I don’t smoke — I’m going to be healthy and live forever,’” he says. “Nobody knows what the future holds. People with perfectly healthy lifestyles get sick every day.”
It costs up to $7,500 to fix a broken leg, about $30,000 for three days in the hospital and into the hundreds of thousands of dollars to treat cancer, HealthCare.gov says. The average visit to an emergency room in 2017 cost $1,389, according to the Health Care Cost Institute.
Most working people can’t cover that kind of expense with their salaries or savings, says Kominski — who, three decades ago as a graduate student, needed an appendectomy that cost $15,000. Because he had a student policy, he says, his share was less than $100.
In addition, health insurance plans that provide free or low-cost preventive services and promote the early identification of problems reduce the likelihood that more expensive and extensive treatment will be needed later, said Jay Wolfson, professor of public health, medicine and pharmacy at the University of South Florida. Thus, they benefit even people who are healthy — or appear to be.
And when healthier people buy insurance, it costs less for everyone, he said.
How To Sign Up for ACA Health Insurance
Start by going to HealthCare.gov and clicking “take the first step to apply” if you plan to enroll for the first time or “login to review/change plans” if you had a 2020 plan through the Marketplace, also known as the “exchange.”
Some states operate their own exchanges. If you live in California, Colorado, Connecticut, Idaho, Maryland, Massachusetts, Minnesota, Nevada, New Jersey, New York, Pennsylvania, Rhode Island, Vermont, Washington or the District of Columbia, you must apply through your state.
Application deadlines are slightly later in Massachusetts, Minnesota, Nevada, New Jersey, New York, Pennsylvania, Rhode Island and the District of Columbia so be sure to call or check your state exchange’s website. In general, coverage begins Jan. 1, 2021.
Online, you’ll learn how to estimate your 2021 income for the application and find a checklist of information you’ll need, such as household size, the Social Security numbers and birthdates of your family members, W-2 forms or pay stubs and policy numbers of any current health insurance. Coverage is available only to U.S. citizens and legal residents.
With insurance through the Marketplace, you’ll pay a deductible and coinsurance — a percentage of a covered health service. The amount varies depending on which plan you choose. You’ll have to pay only up to an out-of-pocket maximum, and there are no yearly or lifetime dollar limits.
You’ll also get the benefit of discounts that insurance companies negotiate with health care providers. People without insurance pay almost two times as much for care, according to HealthCare.gov.
How to Apply, What’s Covered and What Help Is Available
You can apply by phone, in person with help from a navigator — a person specially trained to walk you through the process — through an agent or broker or by mail with a paper application. Volunteers certified by the Marketplace also may be available through nonprofit organizations such as community health centers or hospitals.
Coverage through the Health Insurance Marketplace is intended for those not covered by insurance at work or by government programs such as Medicaid, Medicare, Tricare (for members of the military, veterans and their families) or CHIP, the Children’s Health Insurance Plan.
Plans that comply with the Affordable Care Act cannot discriminate against people with pre-existing conditions. They also must cover birth control and breastfeeding equipment and counseling, plus 10 “essential” services:
- Outpatient care.
- Emergency services.
- Pregnancy, maternity and newborn care.
- Mental health and substance abuse services.
- Prescription drugs.
- Mental and physical rehabilitation for people with injuries, disabilities or chronic conditions.
- Laboratory services.
- Preventive and wellness services and chronic disease management.
- Pediatric treatment, including dental and vision care.
You’ll pay different premiums and out-of-pocket costs depending on the plan you choose. The government will subsidize your premiums if your income is between 100% and 400% of the federal poverty level.
The lower your income, the higher the premium tax credit you’re eligible for (i.e. the help you’ll receive).
What Kind of Plans Are Available?
Insurers sell plans in four categories: Bronze (the least coverage and the lowest premiums), Silver, Gold and Platinum (the most coverage and the highest premiums). Depending on where you live, you may find several types of plans at each level.
You’ll want to make sure your doctors are in the plan you choose and that your prescription medications are covered.
You may have a choice of:
- An exclusive provider organization (EPO), which covers services provided only by doctors and hospitals in a network, except in an emergency. You aren’t required to choose a primary care provider.
- A health maintenance organization (HMO), which requires you to obtain care from doctors who work for or contract with the HMO, except in an emergency. You may have to live or work in the HMO service area.
- A point of service plan (POS), which charges less if you use health care providers that belong to a network and requires you to get a referral from your primary care doctor to see a specialist.
- A preferred provider organization (PPO), in which you pay less for in-network providers, but you can go to out-of-network providers for an additional fee. You don’t need a referral to go to a specialist.
Catastrophic insurance is another alternative available to people younger than 30 and those who can claim a hardship exemption, such as homelessness, domestic violence or bankruptcy. You must apply for the exemption.
On the upside, catastrophic plans cover the 10 essential health benefits, offer specific preventive services for free and cover at least three visits to a doctor annually before the deductible is met. They also cost about one-third as much as more comprehensive plans.
The large downside is that the deductible — the amount the patient has to pay before the insurance company starts sharing the cost — for 2020 was $8,150.. Additionally, these policyholders aren’t eligible for a premium tax credit.
Kominski of UCLA suggests that consumers compare the coverage and cost of a lower-tier plan in the Marketplace before choosing a catastrophic plan.
Susan Jacobson is a former associate editor at Codetic.