Where to start for Affordable Care Act health insurance

Consumers shopping for health insurance plans under the Affordable Care Act could find cheaper premiums for next year, thanks to pandemic relief efforts.

The open enrollment period begins Tuesday and continues through Jan. 15.

That is two weeks longer than previous years, but if you want coverage to begin on Jan. 1, you must enroll by Dec. 15, said Steph Pugh, a certified application counselor with Lifecare Family Health and Dental Center in Canton, a federally qualified health center. Enrollments after Dec. 15 through Jan. 15 would start coverage on Feb. 1, she said.

The plans were created through the Affordable Care Act, also known as the ACA or Obamacare.

This is the 10th annual open enrollment for the ACA plans, which are available for those who don't have health insurance through a job, Medicare, Medicaid or other source.

This year, 14.5 million people — including 259,999 Ohioans — signed up or were automatically reenrolled in these plans. Enrollment for this year was up 21% from the previous year's 12 million enrollees nationwide and 196,806 in Ohio.

Typically, consumers are only able to shop for a new plan outside of the yearly open enrollment period for 60 days after a "life event," such a marriage, divorce, new child, a move or employment change that results in a change to health coverage or loss of coverage.

Coverage can be found through what's called the marketplace, or www.HealthCare.gov.

In a press release, the Centers for Medicare and Medicaid Services said the Inflation Reduction Act is helping to keep costs down for coverage.

Thirteen million Americans will continue to save an average of $800 per year on their health insurance, and 4 out of 5 customers will be able to find a plan for $10 or less after subsidies, according to CMS.

"Also, new standardized plan options are available in 2023, which offer the same deductibles and cost-sharing for certain benefits, and the same out-of-pocket limits as other standardized plan options within the same health plan category," CMS said in the press release. "Most of these standardized plan options offer many services pre-deductible, including primary care, generic drugs, preferred brand drugs, urgent care, specialist visits, mental health and substance use outpatient office visits, as well as speech, occupational, and physical therapy."

Also new this year, families not previously eligible for tax credits may be eligible for financial assistance for the first time ever, CMS said.

This month, the Biden administration finalized a rule that will help about 1 million Americans who are offered employer insurance either gain coverage or get more affordable coverage through the marketplace, according to CMS.

Families who have found employer insurance unaffordable in the past can look for potential savings opportunities on HealthCare.gov.

The following answers are provided by experts at AxessPointe Community Health Centers, a federally qualified health center in the Akron area that offers free help applying for ACA plans. Those seeking help do not need to be current clients of AxessPointe.

AxessPointe's community health workers are also certified application counselors and can help clients find marketplace plans as well as see if they qualify for other assistance, said Marihelyn Horrigan, community impact manager who oversees the workers.

"Our community health workers play a dual role both in navigating the insurance world but also help navigate any social determinants of health that are playing into barriers to care. An example would be a senior who would be food insecure. We could assist with signing up with Mobile Meals," said Horrigan.

Who can apply for an Affordable Care Act plan?

Most people are eligible to apply; however, not everyone is eligible for extra help paying for coverage. Immigrants who are here legally for five years are eligible for ACA insurance.

When dealing with immigration status and insurance, there are quite a few layers to navigate, said Horrigan. It is imperative to not do the application on your own and seek assistance. AxessPointe this year hired a Spanish-speaking community health worker to work with the community, she said.

What do I need to know before signing up for an individual health insurance plan?

Again this year, there is a large marketing push by private health care plans, some of which do not offer the same protections under the ACA rules. Some could turn you down or charge you more if you have a preexisting condition — protections that are included in the ACA plans.

Be sure to know what coverage you are buying. ACA-compliant plans offer the most benefits. That includes what's called the 10 essential health benefits, such as coverage of preventive services like mammograms, pregnancy and newborn care, mental health and addiction services, and prescription drug coverage.

Private insurance websites may not show all plans that you would find on www.HealthCare.gov, the official site for enrollment in ACA plans. There are many look-alike websites.

Additionally, Horrigan cautions against choosing a plan based only on online, TV or mail advertisements or door-to-door salespeople. In some cases, some services that are important to you may not be covered, she said.

"Don't navigate this alone," she said. "Have someone there with you and be wary of scams and read the small print."

Consumers should not pay anyone to help them choose a plan and should pick a plan based on their health needs and not "extras" or perks, she said.

"Know what your medications cost and compare plans," she said. "I cannot stress enough to seek assistance if you are unsure how to proceed. This is a free service. No one should charge to assist in getting signed up."

Also, make sure your doctors and preferred pharmacy are covered in the plan to avoid any disruptions to your care, Horrigan said.

How much is coverage going to cost me?

Costs vary according to plan, family demographics, income and ZIP code. There are tax credits available for some consumers, based on household income. All plans have a maximum out-of-pocket cap, meaning once you have paid that maximum, the plan will pay 100%.

"Every situation is different," said Horrigan. "Do not be discouraged. There is a plan that will fit your need."

I'm uninsured. Am I required to get health insurance?

No. Congress eliminated the federal tax penalty for not having health insurance as of 2019. However, if you choose to go without insurance, you cannot enroll in the ACA plans until the next November's open-enrollment period unless you have a qualifying life event, such as loss of coverage, getting married or having a baby.

If I had a plan last year, does it roll over?

It depends. You may get a letter from your current plan.

It is important to update your application on HealthCare.gov to ensure you receive 2022 premium tax credits and cost-share reductions, even if you are staying with the same company. If you don't update your application, the automatic renewal rates can be much higher than what you can get by signing up for that same plan on HealthCare.gov.

Horrigan said it is still best practice to go over your plan to make sure it still meets your needs.

Where can I find more information?

Information about available plans in your area and enrollment can be found at www.HealthCare.gov or www.CuidadoDeSalud.gov for information in Spanish. Additionally, consumers can call the Marketplace Call Center at 800-318-2596 for assistance or to enroll.

Kaiser Family Foundation also provides a lot of information. See a list of frequently asked questions at www.kff.org/health-reform/faq/health-insurance-marketplace-aca/.

Beacon Journal staff reporter Betty Lin-Fisher can be reached at 330-996-3724 or [email protected]. Follow her @blinfisherABJ on Twitter or www.facebook.com/BettyLinFisherABJ. To see her most recent stories and columns, go to www.tinyurl.com/bettylinfisher.

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