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A Guide to Open Enrollment for 2019

The time to enroll for coverage through the 2019 Health Insurance Marketplace is here. Open enrollment runs through Dec. 15, and it’s a critical time of year for anyone who depends on the marketplace (also known as the health insurance exchange) for healthcare coverage.

The enrollment process will be familiar to anyone who’s previously bought insurance through the exchange. But there are some important changes to the Affordable Care Act for 2019, including the end of the individual mandate that once required people to purchase insurance or face a fine. Depending on where you live, you could also see changes to your plan’s coverage or your premiums.

Whether you’re keeping your plan from last year or looking to enroll through the exchange for the first time, we’ve put together a guide to what you need to know about open enrollment.

When is the open enrollment period?

The 2018 nationwide open enrollment period runs from Nov. 1 until Dec. 15, with insurance plans going into effect on Jan. 1, 2019. A handful of states have extended their deadlines, allowing residents to enroll after Dec. 15 for insurance plans that take effect as late as February or March.

The marketplace open enrollment window may coincide with some employers’ open enrollment periods for health insurance. If you have access to insurance through your job or through your spouse, check with your employer or your partner’s employer for enrollment dates, plan options and other details.

Do I qualify for coverage on the marketplace?

To be eligible for coverage through the marketplace, you must be a U.S. citizen or national who’s living in the U.S., isn’t currently incarcerated and isn’t already insured through your job, a spouse or a parent.

If you or your dependents qualify for Medicaid, Medicare or the Children’s Health Insurance Program (CHIP), you aren’t eligible for marketplace coverage.

One exception: If your employer charges more than 9.86 percent of your yearly household income for health insurance, you can choose to purchase insurance through the marketplace instead.

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How can I enroll?

You can enroll for coverage online, over the phone, with in-person help from an assister, through an agent or broker, or by mail.

If you previously enrolled with the help of an in-person navigator, it might be more difficult to do that this year. The Trump administration cut funding for navigators to $10 million for 2019, down from $36.8 million the previous year and $63 million the year before that.

“Those living in rural areas will be the most affected by these cuts, as these programs may not have the budget to conduct outreach there,” said Rosemarie Day, founder and CEO of Day Health Strategies and previously the founding chief operating officer of the Massachusetts health exchange.

What if I don’t want health insurance? Will I have to pay a fine?

New this year, you can choose to forego coverage without facing a penalty. At the end of 2017, Congress passed a tax bill that repealed the individual mandate, which required individuals to buy health insurance. Up until now, you could be hit with a fine equal to 2.5 percent of your household income or $695 per person — whichever was higher — for opting out of health insurance.

Without the individual mandate, people who are generally healthy might be more likely to skip coverage, says Harry Nelson, founder of the healthcare law firm Nelson Hardiman and co-author of the book From Obamacare to Trumpcare: Why You Should Care. The repeal could also have an impact on people who remain insured.

“What we end up with is a risk pool that’s older and sicker,” Nelson said. “By letting the population that we call the ‘young invincibles’ stay out of the market, we’ve essentially worsened the risk pools and made insurance more expensive for everyone that’s still in the pool.”

Are premiums going up in 2019?

The average increase in premiums across the country is only around 3 percent, Day says, which is on par with inflation. But that average doesn’t account for differences across state lines.

“There will be a lot of variation among states,” she said. “Prices will go up or down depending on which state you live in and which carrier you use.”

In states where premiums are going up, the cost for insurance companies to treat sick enrollees is part of the equation.

“There are some unique issues driving up premiums, like the expansion of addiction treatments and mental healthcare,” Nelson said. “Many of the insurance companies are still adjusting to the broadened scope of care and are having difficulty controlling costs.”

What do I need to prepare before I enroll?

You’ll need to provide basic information about your household size, as well as employer and income information for every person in your household. Walk through this checklist from the Department of Health and Human Services to get ready for enrollment.

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What kind of plan do I need?

As you compare plans, you’ll see options in four categories: Bronze, Silver, Gold and Platinum. In general, Bronze plans have the lowest premiums, which increase as you progress to Silver, Gold and Platinum.

Weighing lower premiums vs. broader coverage

The tradeoff for plans with lower premiums is that they generally cover fewer medical expenses. Likewise, if you pay a higher premium for a higher-tier plan, you’ll usually receive better coverage for the procedures, prescriptions and services you need. But the categories aren’t indicators of the quality of care — they only represent the scope of each plan’s coverage.

Although Gold and Platinum plans come with higher monthly premiums, these plans are usually a good option for people who need frequent medical care or prescriptions. If you don’t expect to make regular visits to the doctor, you might be comfortable with a Bronze plan.

If you’re under 30, you may be eligible for a catastrophic plan, which comes with a low premium and a high deductible. Coverage doesn’t kick in until you meet the $7,900 deductible, so these plans are intended to provide coverage only in the case of an unexpected disaster.

EPO, HMO, POS or PPO: Which is right for me?

Some plans let you choose your own doctors, but others only cover services from a pool of in-network providers.

Exclusive provider organization (EPO) plans and health maintenance organization (HMO) plans only cover providers within your plan’s network. Point of service (POS) and preferred provider organization (PPO) plans cover visits to doctors whether or not they’re in the network, but in-network providers are still usually less expensive, and some plans may require a referral for out-of-network doctors.

If you have a favorite doctor or you want to confirm coverage for a specific procedure or prescription, read the plan’s details as you shop around to make sure you’ll be covered before you enroll.

Will my current plan’s coverage change in 2019?

The Affordable Care Act guarantees 10 essential health benefits, which include preventive services, prescriptions, pregnancy and childbirth care, and mental health services, among others.

But when the Trump administration released its final rule for ACA implementation earlier this year, it gave states new leeway to define their own “benchmark” plans.

“Since the 10 essential health benefits are somewhat broad,” Day said, “each state picks what is called a ‘benchmark plan,’ which establishes a minimum level of coverage at a more detailed level of specificity, which all plans in the state must adhere to.”

The 10 essential health benefits are still safe, Day says, but states could take advantage of the leeway to cut back on coverage in certain areas. This new flexibility allowed Alabama to reduce the number of prescription drugs it would cover, while Illinois took the opposite approach, expanding its benchmark plan to cover a wider range of chronic pain treatments and mental health services, according to Modern Healthcare.

“What we’re seeing is a split between some of the more liberal, blue states which are really holding the line and sticking to the original benefits,” Nelson said, “and some more conservative states that are looking at the financial challenges in the plans and considering reductions.”

Do I qualify for a subsidy to help cover costs?

Your eligibility for a subsidy or premium tax credit depends on your income and the number of people in your household. You can use this calculator to see if you qualify for any savings. If you don’t qualify for savings, you may still be able to purchase a plan through the marketplace at full price.

How likely is a repeal-and-replace of the ACA?

When Donald Trump was elected president in 2016, talk of efforts to repeal and replace the ACA (also known as Obamacare) quickly picked up steam, but attempts from Republicans in Congress have thus far been unsuccessful.

Nevertheless, the administration has succeeded in dismantling key components of the ACA by eliminating the individual mandate and granting more flexibility to states. For now, Nelson doubts that a full repeal-and-replace effort will come to fruition.

“My sense is there is not as strong a political will for further repeal of Obamacare,” Nelson said. “I think the administration got the victory it wanted, and my sense is that Republicans are going to move on to other issues.”

What if I miss the open enrollment period?

If you miss the Dec. 15 deadline, you can still enroll if you qualify for a Special Enrollment Period. Certain life events, like getting married, losing coverage or having a baby, qualify you to enroll outside of the open enrollment period. This questionnaire will help you determine if you qualify.

Show Comments (4)
  1. Miko

    Really helpful article! Thank you for sharing this information.

  2. ES Fred

    Thank you for the insights. The article does not state whether or not you will need to re-apply if you had health insurance through the marketplace in 2018.

    If you had coverage and decide to keep the same plan, do you need to reapply?

  3. Eliza

    Great intro article for open market health care coverage. Love the site. Love ZocDoc. This is great easy to digest information for someone who is interested in open market coverage.

  4. Page

    Thanks so much for this! The exchange can feel overwhelming, and this article does a great job of laying out all the info I’ll need to make decisions. I’m feeling much more equipped now to tackle the process.

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