Open Enrollment for Marketplace Health Plans Is Soon. Here’s What You Need to Know.

It’s fall again, meaning shorter days, cooler temperatures, and open enrollment for Affordable Care Act marketplace insurance — sign-ups begin this week for coverage that starts Jan. 1, 2023. Even though much of the coverage stays the same from year to year, there are a few upcoming changes that consumers should note this fall, especially if they are having trouble buying expensive policies through their employer.

In the past year, the Biden administration and Congress have taken steps — mainly related to premiums and subsidies — that will affect 2023 coverage. Meanwhile, confusion caused by court decisions may trigger questions about coverage for preventive care or for abortion services.

Open enrollment for people who buy health insurance through the marketplaces begins Nov. 1 and, in most states, lasts through Jan. 15. To get coverage that begins Jan. 1, enrollment usually must occur by Dec. 15.

Many people who get coverage through their jobs also must select a plan at this time of year. And their decisions could be affected by new ACA rules.

So, what’s new, and what should you know if you’re shopping? Here are five things to keep in mind.

1. Some Families Who Did Not Qualify for ACA Subsidies Now Do

One big change is that some families who were barred from getting federal subsidies to help them purchase ACA coverage may now qualify.

A rule recently finalized by the Treasury Department was designed to address what has long been termed the “family glitch.” The change expands the number of families with job-based insurance who can choose to forgo their coverage at work and qualify for subsidies to get an ACA plan instead. The White House estimates that this adjustment could help about 1 million people gain coverage or get more affordable insurance.

Before, employees could qualify for a subsidy for marketplace insurance only if the cost of their employer-based coverage was considered unaffordable based on a threshold set each year by the IRS. But that determination took into account only how much a worker would pay for insurance for himself or herself. The cost of adding family members to the plan was not part of the calculation, and family coverage is often far more expensive than employee-only coverage. The families of employees who fall into the “glitch,” either go uninsured or pay more through their jobs for coverage than they might if they were able to get an ACA subsidy.

Now, the rules say eligibility for the subsidy must also consider the cost of family coverage.

“For the first time, a lot of families will have a real choice between an offer of employer-sponsored coverage and a marketplace plan with subsidies,” said Sabrina Corlette, a researcher and co-director at Georgetown University’s Center on Health Insurance Reforms.

Workers will now be able to get marketplace subsidies if their share of the premium for their job-based coverage exceeds 9.12% of their expected 2023 income.

Now, two calculations will occur: the cost of the employee-only coverage as a percentage of the worker’s income and the cost of adding family members. In some cases, the worker may decide to remain on the employer plan because his or her payment toward coverage falls below the affordability threshold, but the family members will be able to get a subsidized ACA plan.

Previous legislative efforts to resolve the family glitch failed, and the Biden administration’s use of regulation to fix it is controversial. The move might ultimately be challenged in court. Still, the rules are in place for 2023, and experts, including Corlette, said families who could benefit should go ahead and enroll.

“It will take a while for all that to get resolved,” she said, adding that it is unlikely there would be any decision in time to affect policies for 2023.

An Urban Institute analysis published last year estimated that the net savings per family might be about $400 per person and that the cost to the federal government for new subsidies would be $2.6 billion a year. Not every family would save money by making the change, so experts say people should weigh the benefits and potential costs.

2. Preventive Care Will Still Be Covered Without a Copay, but Abortion Coverage Will Vary

Many people with insurance are happy when they go in for a cancer screening, or seek other preventive care, and find they don’t have to pay anything out-of-pocket. That comes from a provision in the ACA that bars cost sharing for a range of preventive services, including certain tests, vaccines, and drugs. But a September ruling by U.S. District Judge Reed O’Connor in Texas led to confusion about what might be covered next year. The judge declared unconstitutional one method the government uses to determine some of the preventive treatments that are covered without patient cost sharing.

Ultimately, that might mean patients will have to start paying a share of the cost of cancer screenings or drugs that prevent the transmission of HIV. The judge has yet to rule on how many people the case will affect. But, for now, the ruling applies only to the employers and individuals who brought the lawsuit. So, don’t worry. Your no-cost screening mammogram or colonoscopy is still no-cost. The ruling is likely to be appealed, and no decision is expected before the start of the 2023 coverage year.

The other court decision that has raised questions is the Supreme Court ruling that overturned the constitutional right to an abortion. Even before that decision was announced in June, coverage of abortion services in insurance plans varied by plan and by state.

Now it’s even more complicated as more states move to ban or restrict abortion.

State insurance rules vary.

Twenty-six states restrict abortion coverage in ACA marketplace plans, while seven states require it as a benefit in both ACA plans and employer plans purchased from insurers, according to KFF. Those states are California, Illinois, Maine, Maryland, New York, Oregon, and Washington.

Employees and policyholders can check insurance plan documents for information about covered benefits, including abortion services.

3. Premiums Are Going Up, but That May Not Affect Most People on ACA Plans

Health insurers are raising premium rates for both ACA plans and employer coverage. But most people who get subsidies for ACA coverage won’t feel that pinch.

That’s because the subsidies are tied to the cost of the second-cheapest “silver” plan offered in a marketplace. (Marketplace plans are offered in colored “tiers,” based on how much they potentially cost policyholders out-of-pocket.) As those baseline silver plans increase in cost, the subsidies also rise, offsetting all or most of the premium increases. Still, shop around, experts advise. Switching plans might prove cost-effective.

As for subsidies, passage this summer of the Inflation Reduction Act guaranteed that the enhanced subsidies that many Americans have received under legislation tied to the covid-19 pandemic will remain in place.

People who earn up to 150% of the federal poverty level — $20,385 for an individual and $27,465 for a couple — can get an ACA plan with no monthly premium. Consumers who earn up to 400% of the federal poverty level — $54,360 for an individual and $73,240 for a couple — get sliding scale subsidies to help offset premium costs. People with incomes more than 400% are required to pay no more than 8.5% of their household income toward premiums.

For those with job-based insurance, employers generally set the amount workers must pay toward their coverage. Some employers may pass along rising costs by increasing the amounts taken out of paychecks to go toward premiums, setting higher deductibles, or changing health care benefits. But anyone whose share of their job-based coverage is expected to exceed 9.12% of their income can check to see whether they qualify for a subsidized ACA plan.

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4. Debts to Insurers or the IRS Won’t Stop Coverage

Thank covid for this. Typically, people who get subsidies to buy ACA plans must prove to the government on their next tax filing that they received the correct subsidy, based on the income they actually received. If they fail to reconcile that with the IRS, policyholders would lose eligibility for the subsidy the next time they enroll. But, because of ongoing covid-related problems in processing returns at the IRS, those consumers will get another reprieve, continuing an effort set in place for the tax year 2020 by the American Rescue Plan Act.

Also, insurers can no longer deny coverage to people or employers who owe past-due premiums for previous coverage, said Karen Pollitz, a senior fellow at KFF. This follows a reexamination of a wide variety of Medicare and ACA rules prompted by an April executive order from President Joe Biden.

“If people fell behind on their 2022 premiums, they nevertheless must be allowed to reenroll in 2023,” Pollitz said. “And when they make the first-month premium payment to activate coverage, the insurer must apply that payment to their January 2023 premium.”

5. Comparison Shopping Will Likely Be Easier

Although ACA plans have always been required to cover a wide range of services and offer similar benefits, variation still existed in the amounts that patients paid for office visits and other out-of-pocket costs. Starting during this year’s open enrollment, new rules aimed at making comparison easier take effect. Under the rules, all ACA health insurers must offer a set of plans with specific, standardized benefits. The standard plans will, for example, have the same deductibles, copays, and other cost-sharing requirements. They will also offer more coverage before a patient has to start paying toward a deductible.

Some states, such as California, already required similar standardization, but the new rules apply nationally to health plans sold on the federal marketplace, healthcare.gov. Any insurer offering a nonstandard plan on the marketplace must now also offer the standardized plans as well.

Under a different set of rules, starting Jan. 1, all health insurers must make available cost-comparison tools online or over the phone that can help patients predict their costs for 500 “shoppable services,” such as repairs to a knee joint, a colonoscopy, a chest X-ray, or childbirth.

Julie Appleby:
jappleby@kff.org,
@Julie_Appleby