Amputee Coalition Fact Sheet

ACA Marketplace 2021 Special Enrollment Period

Web Management Fact Sheet

Updated 03/2021

Introduction

Due to the COVID-19 pandemic, the Centers for Medicare & Medicaid Services (CMS) will provide a Special Enrollment Period (SEP) for individuals and families to apply and enroll in health insurance coverage.

If you need to sign up for health insurance, you may do so during the Special Enrollment Period through the insurance exchanges, called marketplaces. These insurance exchanges have been set up in each state. The insurance marketplaces will allow you to compare costs and coverage of various insurance plans and help you determine if you qualify for discounts or tax credits to help cover the costs of your health insurance. This fact sheet will help you navigate the system and choose a health insurance plan that is right for you and your family.

There have been changes in the deadlines, and it is important to consider all levels of plans and check information at healthcare.gov as well as on your state exchange.

Special Enrollment Dates for 2021

The Special Enrollment Period for purchasing plans through the Insurance Marketplace for 2021 begins February 15, 2021 and will continue through August 15, 2021. However, depending on when you sign up for insurance, your coverage will begin at different times. Individuals and families who are eligible and enroll under the new SEP will be able to select a plan with coverage that starts prospectively the first of the month after their plan selection.

Current enrollees will be able to change to any available plan in their area without restriction to the same level of coverage as your current plan. In order to change coverage, you will need to update your application with your current information and submit the application in order to receive an updated eligibility result.

Per CMS, this Special Enrollment Period will not involve any new application questions or need you to provide any new information not otherwise required to determine eligibility. Additionally, you will not need to provide any documentation of a qualifying event (like the loss of a job or birth of a child) which is normally required for SEP eligibility.

How Do I Enroll in Health Insurance?

You have a few options when it comes to enrolling in health insurance coverage. If you do not already have insurance, you may:

  • Enroll in a coverage plan offered by your employer
  • Enroll in Medicare/Medicaid in your state if you are eligible
  • Use your state’s marketplace or federal healthcare.gov (if your state is not listed below) to enroll in a private health insurance plan
  • Independently search for a private health insurance plan that fits your needs

If you live in any of the following states, your health insurance marketplace is run by your state, which means that healthcare.gov will redirect you to your state exchange or you can go directly to your state’s marketplace:

California
Colorado
Connecticut
District of Columbia
Idaho
Maryland
Massachusetts
Minnesota
New York
Rhode Island
Vermont
Washington

If you live in a state other than the ones listed above, go online to healthcare.gov and click “Get Coverage” for coverage options in your state and to find out more about the marketplaces.

If you have questions about the health insurance marketplaces and would like to speak to someone about your options and to help you navigate your marketplace, you can contact the Health Insurance Marketplace help center toll-free at (800) 318-2596.
TTY: (855) 889-4325

What Should I Look For in a Plan?

The most important things to compare in health insurance plans are premium costs, total costs, and coverage.

Costs: Once enrolled in a health insurance plan, you are responsible for various costs.

Premiums Premiums are the amount that you pay for your insurance plan. Typically, you pay your premium monthly, quarterly, or annually. Premiums must be paid on time to ensure continued coverage.
Deductible A deductible is the amount that you pay for healthcare services before your health insurance plan begins to pay. For example, if your insurance plan has a deductible of $2,500, the insurance company won’t pay anything until you’ve met the $2,500 deductible of healthcare services subject to the deductible.
Coinsurance Coinsurance is a percentage of the total cost for a healthcare service that you pay. For example, if the health insurance or plan’s allowed amount for an office visit is $100 and you’ve met your deductible, your coinsurance payment of 20% would be $20. The health insurance or plan pays the rest of the allowed amount.
Copay A copay is a fixed amount that you pay for a healthcare service. This often applies to office visits and prescriptions. For example, a doctor’s office visit might have a copay of $30 that you will owe at the time of service. The copay for an emergency room visit will usually cost more, such as $150.
Out-of-Pocket Maximums Out-of-pocket maximums are the maximum you will pay for all services in the year of your policy before your insurance will cover 100% of the remaining costs. This can help to protect you from very high healthcare costs. The maximum out-of-pocket cost limit for any individual Marketplace plan for 2019 can be no more than $7,900 for an individual plan and $15,800 for a family plan.

 

Coverage: Coverage varies according to each unique plan. Be sure to compare the different types of healthcare service coverage that each plan offers so that you choose the one that is right for you and your family based on your specific needs. Below are some of the things to consider when comparing health care coverage.

Annual Limits and Exclusions Insurance companies can still restrict or cap specified services that are not specifically considered Essential Health Benefits. Only 20 states don’t allow annual limits and exclusions for prosthetic devices. In some instances, you may also find insurance plans restrict the types of devices they cover. Common exclusions to be aware of are for “bionic, biomechanical, robotic and microprocessor” devices.
Preferred Healthcare Professionals It is important to find out if your preferred physician, prosthetist and/or physical therapist will take the insurance plan you are considering so that you don’t end up paying “out of network” charges or need to change healthcare providers.

 

Additional Concerns: Does your employer offer a plan that fits your needs? Do you qualify for a subsidy to purchase an insurance plan on the Health Insurance Marketplace? Do you qualify for a government healthcare program? Are better options available by purchasing your own insurance and tailoring it for your needs? These are all important considerations, but only you can make the decision that is right for you. Remember to look into all options!

How Does This Affect Me?

The Affordable Care Act established provisions relating to Essential Health Benefits (EHB). An Essential Health Benefit is a benefit that insurance policies must cover in order to be certified and offered in the marketplace. If a benefit is deemed an EHB, then that benefit cannot be subject to caps. Marketplace plans must include habilitative and rehabilitative services and devices in every state except Utah. States expanding their Medicaid programs must also provide these benefits to people newly eligible for Medicaid.

The statute itself established 10 categories of EHBs that must be covered. These 10 categories are:

  • Ambulatory patient services
  • Emergency services
  • Hospitalization
  • Maternity and newborn care
  • Mental health and substance abuse disorder services, including behavioral health treatment
  • Prescription drugs
  • Rehabilitative and habilitative services and devices
  • Laboratory services
  • Preventive and wellness services and chronic disease management
  • Pediatric services, including oral and vision care.

There is some variation amongst the states because the Department of Health and Human Services elected to allow states to define their own EHBs. This causes three major problems:

  1. There is not consistency in EHBs from one state to another.
  2. The state benchmark plan can “cut a corner” by offering some benefit in all categories, even if that benefit is deficient.
  3. If you move from one state to another, benefits that your plan provided in your home state may not be available to you in your new state.

The Amputee Coalition worked with states as well as partners and coalition members to stress the importance of prosthetic and custom orthotic benefits in every state’s EHBs. Unfortunately, many states did not explicitly include prosthetic devices in their EHBs. However, nearly every state appears to have at least some level of coverage for prosthetic care. It is very important that if you are interested in shopping for insurance in your state’s marketplace, that you confirm the level of coverage for not only prosthetic care, but any other healthcare needs you may have. The table at the end of this document provides a breakdown of the prosthetic care and device coverage that each state offers.

If your state has determined that prosthetic devices are an Essential Health Benefit, but the marketplace plans still include caps or restrictions on care, the Amputee Coalition needs your help in raising awareness of this issue with your state legislatorsgovernor, and state insurance commissioner to ensure Essential Health Benefits, including prosthetic care, are not capped (as the law intended). If your state’s marketplace does not cover prosthetic devices in the marketplace plans, does not provide enough coverage, or includes caps or restrictions on prosthetic coverage, you can work with the Amputee Coalition to raise awareness with state officials, and help us pass Insurance Fairness for Amputees in your state.

What If I Don’t Enroll During Open Enrollment?

If you miss the open enrollment period, you may be able to take advantage of other opportunities to enroll in health insurance:

  • Outside Open Enrollment, you can buy a health insurance plan onlyif you qualify for a Special Enrollment Period due to a qualifying life event. This is true for plans available outside the Marketplace, too. Qualifying life events that will allow you to enroll in a Special Enrollment Period include things such as marriage or divorce, having a baby, or losing other health coverage due to various circumstances, etc.
  • You can apply for Medicaid and the Children’s Health Insurance Program (CHIP) any time of year. If you qualify, you can enroll immediately.
  • Members of federally recognized tribes and Alaska Native Claims Settlement Act (ANCSA) Corporation shareholders can enroll in Marketplace coverage any time of year. There is no limited enrollment period for these groups, and they can change plans as often as once a month.

What Is the Penalty for Not Having Health Insurance?

Starting with the 2019 calendar year, there’s no federal penalty for not having coverage. Note: This change took effect with 2019 taxes, which were filed in early 2020.

Short-Term Limited Duration Plans

Short-term, limited duration (STLD) health insurance was designed for individuals who experienced a temporary gap in health insurance coverage. In 2018, the previous administration redefined what qualifies as a short-term, limited duration health plan. Under the new rule, these plans can now last under 12 months and can be renewed for up to three years. There are several things to consider when looking into a short-term, limited duration plan:

  • Short-term plans can turn you down or refuse to cover any pre-existing condition. These plans can also charge you higher premiums if you have a pre-existing condition.
  • Most short-term plans don’t provide coverage for prescription drugs.
  • If you have, or anticipate having, expensive medical needs, short-term plans can cap how much they will pay in benefits.
  • Short-term plans do not cover maternity benefits.
  • If you use mental health services or substance abuse disorder treatment, most short-term plans don’t cover these services.
  • Short-term plans have higher deductible amounts and don’t have to limit patient out-of-pocket spending.

If you are considering purchasing a short-term, limited duration plan, be sure to check the policy carefully to make sure what the policy does and does not cover. Also, if this coverage expires or you lose eligibility, you may have to wait until an open enrollment period to get other health insurance coverage.


Table 1.1: U.S. State and Territory Coverage of Prosthetics

State Are Prosthetic Devices Considered an Essential Health Benefit? Are Prosthetic Devices Covered?
Alabama Yes Yes, with exclusions
Alaska Yes Yes, with exclusions
Arizona Yes Yes, with exclusions
Arkansas Yes Yes, with exclusions
California Yes Yes, with exclusions
Colorado Yes Yes, with exclusions
Connecticut Yes Yes, with exclusions
Delaware Yes Yes, with exclusions
Florida Yes Yes, with exclusions
Georgia Yes Yes
Hawaii Yes Yes, with exclusions
Idaho Yes Yes, with exclusions
Illinois Yes Yes, with exclusions
Indiana Yes Yes, with exclusions
Iowa Yes Yes
Kansas Yes Yes, with exclusions
Kentucky Yes Yes, with exclusions
Louisiana Yes Yes, with exclusions
Maine Yes Yes, with exclusions
Maryland Yes Yes, with exclusions
Massachusetts Yes Yes
Michigan Yes Yes, with exclusions
Minnesota Yes Yes, with exclusions
Mississippi Yes Yes, with exclusions
Missouri Yes Yes, with exclusions
Montana Yes Yes, with exclusions
Nebraska Yes Yes, with exclusions
Nevada Yes Yes, with exclusions
New Hampshire Yes Yes, with exclusions
New Jersey Yes Yes, with exclusions
New Mexico Yes Yes, with exclusions
New York Yes Yes, with exclusions
North Carolina Yes Yes
North Dakota Yes Yes, with exclusions
Ohio Yes Yes, with exclusions
Oklahoma Yes Yes, with exclusions
Oregon Yes Yes, with exclusions
Pennsylvania Yes Yes
Rhode Island Yes Yes, with exclusions
South Carolina Yes Yes
South Dakota Yes Yes
Tennessee Yes Yes, with exclusions
Texas Yes Yes, with exclusions
Utah No No
Vermont Yes Yes, with exclusions
Virginia Yes Yes, with exclusions
Washington Yes Yes
West Virginia Yes Yes
Wisconsin Yes Yes, with exclusions
Wyoming Yes Yes, with exclusions
Washington, D.C. Yes Yes, with exclusions
America Samoa Information not available Information not available
Guam Information not available Information not available
Mariana Islands Information not available Information not available
Puerto Rico Information not available Information not available
Virgin Islands Information not available Information not available
Source: The Amputee Coalition and Centers for Medicare & Medicaid Services

To further explore coverage for prosthetic devices and DMEs in your state, visit https://www.cms.gov/CCIIO/Resources/Data-Resources/ehb

Additional Resources

To learn more about the 2021 Special Enrollment Period, please visit https://www.cms.gov/newsroom/fact-sheets/2021-special-enrollment-period-response-covid-19-emergency.

If you miss the Open Enrollment deadline, visit healthcare.gov/coverage-outside-open-enrollment/special-enrollment-period to learn more about Special Enrollment Periods and to see if you qualify.

To learn more about Medicaid and CHIP programs, visit healthcare.gov/coverage-outside-open-enrollment/medicaid-chip.

To explore your Medicare options, visit medicare.gov/find-a-plan or call (800)-MEDICARE.

To learn about subsidies that may help you save on Medicare costs, visit nasuad.org/initiatives/state-health-insurance-programs/medicare-improvements-patients-and-providers-act.


It is not the intention of the Amputee Coalition to provide specific medical or legal advice but rather to provide consumers with information to better understand their health and healthcare issues. The Amputee Coalition does not endorse any specific treatment, technology, company, service or device. Consumers are urged to consult with their healthcare providers for specific medical advice or before making any purchasing decisions involving their care.

This project was supported, in part, by grant number 90LLRC0001-01-00, from the Administration for Community Living, U.S. Department of Health and Human Services, Washington, D.C. 20201. Grantees undertaking projects under government sponsorship are encouraged to express freely their findings and conclusions. Points of view or opinions do not, therefore, necessarily represent official Administration for Community Living policy.

© Amputee Coalition. Local reproduction for use by Amputee Coalition constituents is permitted as long as this copyright information is included. Organizations or individuals wishing to reprint this article in other publications, including other World Wide Web sites must contact the Amputee Coalition for permission to do so.