ACA open enrollment – The Basics


Open enrollment for the Affordable Care Act started on November 1, 2015. The first and most important deadline is December 15, 2015. You must enroll or make changes by this date in order for a new policy to take effect by January 1st. Before making a decision, here’s what you need to know about this coming year’s open enrollment:

  • Enrollment for the ACA Marketplace for 2016 runs from November 1, 2015 to January 31, 2016.
  • Consumers can enroll inside or outside of the Marketplace.
  • This ACA open enrollment period applies to new enrollees or those wishing to make changes in last year’s plans or coverage options.
  • Open enrollment is the only time a consumer can enroll in a medical plan (which counts as minimum essential coverage or MEC), switch plans, or apply for assistance with costs, or subsidies.
  • Log onto to access programs by state.
  • If you have Medicare you cannot purchase a new individual policy.

When does coverage start?

A person enrollingMoney and time paid picture dreamstime_m_38644784 November 1, 2015 to December 15, 2015 will see a start in coverage as soon as January 1, 2016.

A person waiting until January 15, 2016 to enroll or change plans will start new coverage on February 1, 2016.

Anyone who enrolls or change plans between January 16, 2016 and January 31, 2016 will have new coverage taking effect on March 1, 2016.

The open enrollment period of the ACA Marketplace will end on January 31, 2016.

If you don’t enroll in a plan the ACA considered minimum essential coverage (MEC) by January 31, 2016, you will not be able to enroll in a health insurance plan for the entire year unless you qualify for a special enrollment period.

A few tips for navigating the ACA marketplace

#1 Subsidies to help with premium costs can only be obtained through the health insurance marketplace.

#2 The law requires individuals to obtain minimum essential coverage, and must carry that coverage through the year to avoid paying a per month fee when not insured. The only way to avoid this fee is to gain an exemption. Any plans offered by the marketplace are considered minimum essential coverage.

#3 If you missed the initial enrollment period, you are unable to sign up again until the next open enrollment, except in the case where you can qualify for a special enrollment. For example, a person who was unable to qualify for Children’s Health Insurance Program (CHIP) or Medicaid may be able to qualify for a special enrollment. Losing employer based insurance or COBRA are also considered qualifying events.

#4 Medicaid and CHIP does not have a limited enrollment period. Consumers can apply at any time.

What’s considered minimum essential coverage?

The ACA considers minimum essential coverage a type of health plan (includes individual policies) bought within the health insurance marketplace, other sources, received from a job, or from Medicare, Medicaid, CHIP, TRICARE (military), and others. The ACA does not consider the following as minimum essential coverage in order to avoid fine:

  •  Vision and dental care only
  • Worker’s compensation
  • Medical service discount plans
  • Specific disease or specific condition coverage only

What about penalty fees?

Entering its third year, Affordable Care Act coverage costs continue to increase. National average premium costs are expected to rise by approximately 7.5% that use the marketplace. Premiums for large insurers are expected to rise 25% to 43% in other states, including Tennessee, Oregon, South Dakota, and Maryland. High deductibles have also soured enthusiasm for many, with deductibles averaging $3,000. However, a Bronze plan comes with a deductible of $5,731 while Silver plans average $3,117. As deductibles decrease, premiums increase. Before coverage even begins these high deductibles cause financial strain that leads to hard decisions and choices for many.

The penalty fee for not having health insurance coverage in 2016 will be charged for every month you are not covered. Fees are calculated in two ways: either as a percentage of household income – 2.5% of household income or the total yearly premium that an average bronze plan would cost. Or a per person fee ($695 per adult and $347.50 for children under 18 years of age) with a maximum fee of $2,085. You’ll pay whichever is higher.
The IRS will hold back penalty fee amounts from future tax refunds, but consumers will not face criminal penalties, levies, or liens against them if the fee is not paid.

Mental Health Parity Still a Distant Wish for Most

Mental health parity remains a constant battle for young and middle aged populations of Americans seeking mental health services for drug and alcohol abuse, eating disorders, rape counseling, and posttraumatic stress disorders (PTSD). The challenges that such individuals face often go against insurance “standards” when it comes to provision of care. Unfortunately, when it comes to mental health and issues, the watchwords of most insurance companies still utilize the acute care standard – “if not suicidal, have to discharge”.

The Paul Wellstone Mental Health and Parity Act signed into law in 2008. The act sought to ensure that insurance companies treated mental health issues and substance abuse disorders on the same level as physical illnesses when a person’s insurance policy offers coverage for both. Since then the Affordable Care Act the mental health parity was extended to provide equal benefits with medical coverage, even for individual health insurance coverage.

Unfortunately, actual changes are not taking hold. Mental and substance abuse problems are still considered only on an acute care basis. Regrettably, such issues are often chronic in nature and necessitate long term management.

An alarming number of individuals between the ages of 20 and 30 are finding it increasingly difficult to obtain care coverage for mental health issues and related behaviors. County health services have begun to develop “transition programs” but in some areas, a four plus month wait or longer is typical. Individuals, including those dealing with PTSD, substance abuse, and eating disorders, are either being denied access to such care facilities or are being discharged from their treatment programs early. When an individual’s treatment courses are cut short, they often return home with ineffective coping skills that lead to relapses and in some cases, death.

60 Minutes recently ran a story related to denial of mental health coverage by insurance companies despite doctor’s prescribed orders for treatments of mental health and addictive behavioral issues. In fact, the exposé noted that many insurance adjusters “aggressively” review not only chronic cases, but long-term mental health care needs. Most health insurance companies often deny coverage for full treatment care plans, cutting off benefits at the halfway point.

In an attempt to enhance mental health treatment opportunities, the Affordable Care Act has shown significant improvements for those seeking care in physician and therapist office settings. Unlimited visits are a definite improvement for those with manageable mental health problems. Unfortunately, for those needing intensive outpatient or inpatient services, the quality of care and the number of in-network providers are limited.

Most reputable mental health treatment centers are out-of-network, placing a significant financial burden on patients and their families. Many of these patients are young adults still in college or high school, which creates a volatile situation within the family dynamic. Young adults often blame parents for their substance abuse; divorce, neglect, emotional distance are just a few reasons. Yet most parents paying for their children’s treatment don’t share this blame.

In today’s healthcare economy, insurance companies are the ones who determine duration of treatment, which makes it extremely difficult not only for patients to receive the care they need, but for patients and family members to struggle through the requirements and demands of filing claims, billing and reimbursement for such services.

Real solutions are only possible with genuine consideration from insurance companies. The Alliance of Claim Assistance Professionals (ACAP) strongly urges our readers to file appeals on all levels, as ACAP experience tells us that meaningful review takes place at the Departments of Insurance levels. Significant change will only come by filing mental health denial appeals to state insurance departments.

The Affordable Care Act

The Affordable Care Act is Enabling Everyone to Have Medical Insurance
The Affordable Care Act has given many Americans the opportunity to finally be able to afford and obtain health insurance. Through the Affordable Care Act, Americans can now find affordable medical insurance that covers their healthcare needs.

Also known as Obamacare, the Affordable Care Act is based on a lengthy piece of legislation which assigns power to government programs, on an ongoing basis, to continuously improve and reform health care. Reforms impact funding and spending, taxes, insurance company rules, protections, benefits, rights and more.

Most preventive care services are offered without deductibles. For lower income people, subsidies are available through the Health Insurance Exchanges. Through the Medicaid extension provided by many states more people can apply for state funded medical care.

Providing Access for Uninsured Americans with Pre-Existing Conditions
Before the Affordable Care Act was enacted, many Americans were unable to obtain health insurance due to pre-existing conditions they may have had. These Americans only had hope of obtaining insurance if they could find a full time job that offered health benefits, or if they purchased a very expensive policy which offered coverage for a high risk pool, organized by many states. If they lost said job, then their insurance policies would lapse and they would be uninsured. The Affordable Care Act has made it possible for people with pre-existing conditions to finally obtain their own private health insurance. Through this Act, insurance companies are no longer allowed to turn away any customers.

Extending Coverage for Young Adults
With the ACA, young adults have the ability to stay on their parents’ insurance policy until they are 26 years old. This coverage is available without contingencies based on being a student, living with the parent, being financially dependent or being married. This allows young adults to go to college and get married, without the burden of health insurance over their heads. The majority of young adults can also graduate from college and find a job with benefits before they are taken off of their parents’ insurance policy.

Expanding Coverage for Early Retirees
Often, Americans wish to retire before they become eligible for Medicare. Before the Affordable Care Act, these Americans had to either wait to retire until they became eligible for Medicare, or they had to buy private, expensive insurance plans to cover them for a few years. Now, the Affordable Car Act has created a $5 billion program to provide these seniors with financial help and coverage to cover them between their retirement date and the date they become Medicare eligible.

Offering Free Preventative Care
All of the new insurance plans created by the Affordable Care Act must now cover certain preventative services. Preventative services such as, physicals, mammograms, colonoscopies, and many others are free so that patients can stay healthy as they grow older and enjoy their retirement.

The Affordable Care Act has significantly improved the healthcare market in America. It has allowed numerous people to obtain health insurance for an affordable price, and has helped reduce healthcare costs throughout the country. Through the Affordable Care Act, many people have benefited and will continue to benefit from healthcare services for many years.