If you missed open enrollment, you may still be able to enroll in employer or individual coverage if you experience a “qualifying life event.” A Special Enrollment Period allows you and your family to enroll in health coverage after a “qualifying life event,” such as:
- You move outside your insurance plan’s service area
- You get married
- You have a baby or adopt a child
- You lose other health coverage due to job loss, reduced work hours, or COBRA coverage ends
- You become a U.S. citizen
- You leave incarceration
- You’re a member of an American Indian or Alaska Native tribe. (You can enroll in Marketplace coverage any time of year. You can change plans up to once a month.)
- You’re no longer covered on a family member’s policy because you turned 26 years old
- You have legally separated from, or divorced, your spouse, or the policyholder has passed away
For plan years through 2018, if you could afford health insurance but chose not to buy it, you may have paid a fee called the individual Shared Responsibility Payment when you filed your federal taxes. (The fee is sometimes called the "penalty," "fine," or "individual mandate.")
Starting with the 2019 plan year (for which you’ll file taxes in April 2020), the Shared Responsibility Payment no longer applies.
Note: Some states have their own individual health insurance mandate, requiring you to have qualifying health coverage or pay a fee with your state taxes for the 2019 plan year. If you live in a state that requires you to have health coverage and you don’t have coverage (or an exemption):
- You’ll be charged a fee when you file your 2019 state taxes
- You won’t owe a fee on your federal tax return
There are many circumstances for which you would not be charged a penalty for not being enrolled in a health insurance plan when filing your state or federal taxes. Check Healthcare.gov or ask your tax preparer to find out to find out if there is a fee for not having health coverage.
- You won’t be turned down by a health plan, receive limited coverage or be asked to pay more based on any pre-existing conditions. Many people who had a pre-existing health issue weren’t able to get an affordable health insurance plan before the Affordable Care Act was implemented. Now, having pre-existing health conditions before applying for insurance won’t affect your coverage.
- Parents can keep adult children on their insurance plan. The Affordable Care Act makes it possible for young adult children under the age of 26 to remain on their parent’s health insurance plan. They don’t have to be a full-time student, live with you, be disabled or be a tax dependent.
- Preventive screenings and services are covered. It can be challenging to maintain your health without continuous care. Each qualified health insurance plan covers preventive services at no added cost to you when you use an in-network doctor who takes your insurance plan.
- This includes services like yearly wellness exams, recommended vaccines for children and adults, mammograms, blood pressure screenings, osteoporosis screenings, Type 2 diabetes screenings for overweight adults, diet counseling, and lung cancer screening.
- Your insurance cannot be canceled because of your health status. You won’t be dropped from your insurance just because you’re sick.
- There are no dollar limits on the care you receive for essential health. Your coverage cannot have a dollar limit on essential health benefits while you’re enrolled in that plan.
- It’s a good idea to see if you qualify for Medicare or Medicaid health insurance coverage. If you complete the application on the Health Insurance Marketplace (or BeWellNM.com in New Mexico) website, you will find out what health care coverage programs you qualify for, including Medicare or Medicaid.
You can go online at Healthcare.gov or call 1-800-318-2596 (or BeWellNM.com 1-833-862-3935 in New Mexico) to learn about health insurance plans available in your area. Plans on the Marketplace or Exchange will offer comprehensive health coverage, from doctors to medications to hospital visits.
You can compare all your health insurance options based on price, benefits and other features that may be important to you — all in plain language. You can apply for coverage online, over the phone or with a paper application. Open enrollment is November 1, 2019 through December 15, 2019 for coverage starting in 2020.
All plans on the Marketplace or Exchange include a comprehensive package of health benefits. Plans on the Marketplace or Exchange differ on how the costs of the benefits are shared between you and your plan. Plan categories have nothing to do with quality of care. There are four different categories of plans on the Marketplace (Bronze, Silver, Gold and Platinum).
When you use the Marketplace or Exchange to compare plans, you’ll see prices for all plans available to you. All insurance plans available through the Marketplace or Exchange are offered by private insurance companies. Prices are approved by state insurance departments and/or the federal government. Prices will show any cost savings you may be eligible for based on your income. These lower costs are available only through the Marketplace or Exchange.
The size of your family doesn't necessarily determine what you spend on medical care and prescriptions. A healthy family of six could spend less on a health care plan than a married couple who has serious health conditions.
Yes, you can even purchase a plan on the Marketplace before COBRA runs out. When you leave a job, you may be able to keep your job-based health coverage for a period of time, usually up to 18 months. This is called COBRA continuation coverage.
You may change from COBRA coverage to Marketplace health insurance coverage any time. Losing your COBRA coverage qualifies you to buy health insurance on the Marketplace, even if it’s not during open enrollment. You can visit the Marketplace at any time during the year to find your options, compare plans and enroll.
Small businesses with under 50 full-time equivalent employees are not required by law to offer group health insurance plans for their employees.
Most health care plans have provider (doctor) “networks.” Networks are the groups of hospitals, doctors, pharmacies and other health professionals that the insurance company offering the coverage works with. Your doctor may or may not be included in this network, but your insurance may provide coverage for non-network providers. If keeping your doctor is important to you, be sure to check if they are on the insurance plan you’re considering buying and if the plan provides coverage for out-of-network providers.
Each qualified health insurance plan covers preventive services at no added cost to you when you use an in-network provider. Here are some of the benefits you can expect in your plan:
- Yearly wellness exams
- Recommended vaccines for children and adults (including flu shots)
- Mammograms, blood pressure and osteoporosis screenings
- Diabetes (type 2) screening for overweight adults
- Adult obesity and tobacco use screenings
Yes, you can get dental coverage two different ways when you sign up for new coverage. You may be able to find health care plans that include dental while shopping on the Marketplace or Exchange. If your plan includes health and dental, you’ll only have to pay one premium. If you can’t find a health plan you like that also has dental, you can opt for a standalone dental plan. This separate plan will require a separate premium payment.
Dental coverage under Medicaid or Medicare varies by state.
- Medicaid offers dental health insurance for children, but may only offer emergency dental care for adults, and varies by state.
- Medicare (health care insurance for those 65 and older, younger people with disabilities and people of any age with End-Stage Renal Disease) doesn't cover most dental care or dental procedures. You should consider purchasing a dental health care plan through the Marketplace or Exchange.
If you’ve had difficulty affording health insurance, go online or call the Health Insurance Marketplace or Exchange to determine if you’re eligible for a government insurance program like Medicare or Medicaid. By completing the application, you will find out if you qualify for tax credits and financial assistance to help pay for coverage.
When you shop on the Marketplace or Exchange, you may qualify for a premium credit that’ll lower your monthly insurance cost. Depending on your situation, you may even be eligible for a $0 premium plan. You’ll be able to see what your health insurance premium, deductibles and out-of-pocket costs will be before you make a decision to enroll.
You may qualify for lower costs on monthly premiums. It depends on the size of your family and the size of your household income. Typically, people at lower income levels will qualify for higher subsidies. When you apply for health insurance and fill out your application, you’ll be able to see prices that show any savings you qualify for.
If you are 65 years or older, in most circumstances, you are eligible for Medicare. As a government-funded program, Medicare will cover a large portion of your covered services. Here are some of the features of Medicare:
You can choose your doctor
- You can choose your doctors based on Medicare guidelines. If you’re enrolled in a Medicare Advantage Plan or group health plan, different rules may apply. Check with your health care plan for details.
More preventive services are covered
- Medicare covers certain preventive services, with no added out-of-pocket costs for care such as flu shots, mammograms, osteoporosis screening and immunizations.
You can compare nursing facilities and services
- Skilled nursing facilities publish information about the owners and how they operate. This information helps you compare services.
- High-needs Medicare patients have access to basic health care services in their homes. This will help prevent hospital stays and improve patient satisfaction.
To avoid paying higher costs, it’s a good idea to make sure your doctor is a participating Medicare doctor and, if applicable, in your Medicare plan’s network. In situations where your doctor is not in the plan’s network, you might need to change to a doctor who is in the network. It’s a good idea to check with your doctor before making any appointment to make sure he or she is still in the Medicare plan. Otherwise, you will have to pay out-of-pocket for your doctor’s services.
If you are enrolled in Medicare, you can travel anywhere in the U.S. and still be covered, as long as you receive care from doctors or hospitals that accept Medicare. If you travel outside of the United States, your Medicare coverage is limited.
In some situations, Medicare may cover your care in a foreign hospital outside the U.S.:
- If you have a medical emergency in another country, but the nearest hospital is closer to you than the nearest U.S. hospital.
- When traveling through Canada in transit between Alaska and another U.S. state, you can be treated in a Canadian hospital.
- If you need medical attention while traveling on a cruise ship and are in U.S. waters or a U.S. port (or within six hours of arrival or departure from a U.S. port).
While there are some situations when your medical care is covered outside the U.S., prescription medications that you purchase outside of the U.S. are not covered by Medicare.
Each state has its own Medicaid and Children’s Health Insurance Program (CHIP) primary care provider network. Contact your state for a list of providers near you.
Does Medicaid cover pregnancies, mental health, dental, nursing home, or long-term care?
States are required to cover certain benefits and others are optional. To learn what your state covers, contact your state Medicaid agency. To learn more about the Federal rules around mandatory and optional services, visit the benefits page.
When applying for Medicaid health care coverage, you will be asked to verify your identity and your income. Here are some of the documents you might need:
- Proof of Age/Identify – Birth certificate, passport, driver’s license, military identification card, Social Security card
- Proof of Citizenship – Birth certificate, passport, naturalization papers, alien registration card
- Marital Status – Marriage certificate, divorce decree, separation documentation, spouse’s death certificate
- Income – Paycheck stub, unemployment check, pension statement, child support or alimony check, Social Security retirement award letter
- Financial Records – Checking, savings or money market bank account statements; stocks, bonds, 401k, IRA or trusts
- Household Expenses – Utility bills, insurance, mortgage or rental statements
Qualified health plans cover screenings and services essential to women with no out-of-pocket costs. Simply visit a doctor in your health plan’s provider network. Here are some of the essential benefits:
- Mammograms and pap smears
- Interpersonal and domestic violence counseling
- Counseling and screening for HIV
- Immunizations such as the annual flu shot
- Breastfeeding support, supplies and counseling
Health coverage is available for all kids, even those with medical conditions. To find out what health care coverage plan your child is eligible for, complete the application in the Health Insurance Marketplace or Exchange. Your child could qualify for a low-cost government programs like the Children’s Health Insurance Program (CHIP).
Young adults can stay on their parent’s health plan up to age 26. They don’t have to be a full-time student, live with you, be disabled or be a tax dependent.