Amputee Coalition Fact Sheet

Open Enrollment for Health Insurance Coverage

Web Development Fact Sheet

Updated 10/2018

Introduction

If you decide you need to sign up for a private health insurance plan, you may do so during open enrollment 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.

Open Enrollment Dates for 2019

Open enrollment is a period of time in which individuals and families can enroll in health insurance coverage for the following year.

Open enrollment for purchasing plans through the Insurance Marketplace for 2019 begins November 1, 2018 and ends December 15, 2018. However, depending on when you sign up for insurance, your coverage will begin at different times.

During Open Enrollment, if you enroll:

Between November 1 – December 15, 2018…Your coverage begins January 1, 2019.

If you are currently enrolled in a health insurance plan through the Marketplace, that coverage ends December 31, 2018. You will PROBABLY be automatically renewed for the same or similar plan you currently have unless you choose a different plan during open enrollment. Since your circumstances may have changed, it is strongly recommended that you review your options and complete a 2019 application. You MUST update household and income information on your 2019 application to receive the appropriate level of savings.

If you qualify for Medicare, you can sign up during Medicare open enrollment which begins October 15 and ends December 7, 2018.

1. 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. States expanding their Medicaid programs must provide these benefits to people newly eligible for Medicaid. The statute itself establishes 10 categories of EHBs that, in theory, must be covered by every insurance plan that is going to receive any federal money. 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.

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 their 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 following table provides a breakdown of the coverage that each state offers.


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

StateAre Prosthetic Devices Considered an Essential Health Benefit?Are Prosthetic Devices Covered?
AlabamaYesYes, with exclusions
AlaskaYesYes
ArizonaYesYes, with exclusions
ArkansasYesYes, with exclusions
CaliforniaYesYes, with exclusions
ColoradoYesYes
ConnecticutYesYes, with exclusions
DelawareYesYes, with exclusions
FloridaYesYes, with exclusions
GeorgiaYesYes
HawaiiYesYes, with exclusions
IdahoYesYes
IllinoisYesYes, with exclusions
IndianaYesYes
IowaYesYes
KansasYesYes, with exclusions
KentuckyYesYes, with exclusions
LouisianaYesYes, with exclusions
MaineYesYes, with exclusions
MarylandYesYes
MassachusettsYesYes
MichiganYesYes, with exclusions
MinnesotaYesYes, with exclusions
MississippiYesYes
MissouriYesYes
MontanaYesYes, with exclusions
NebraskaYesYes, with exclusions
NevadaYesYes, with exclusions
New HampshireYesYes
New JerseyYesYes
New MexicoYesYes, with exclusions
New YorkYesYes, with exclusions
North CarolinaYesYes
North DakotaYesYes, with exclusions
OhioYesYes
OklahomaYesYes, with exclusions
OregonYesYes, with exclusions
PennsylvaniaYesYes
Rhode IslandYesYes, with exclusions
South CarolinaYesYes, with exclusions
South DakotaYesYes
TennesseeYesYes, with exclusions
TexasYesYes
UtahNoNo
VermontYesYes, with exclusions
VirginiaYesYes, with exclusions
WashingtonYesYes
West VirginiaYesYes
WisconsinYesYes, with exclusions
WyomingYesYes, with exclusions
Washington, D.C.YesYes, with exclusions
America SamoaInformation not availableInformation not available
GuamInformation not availableInformation not available
Mariana IslandsInformation not availableInformation not available
Puerto RicoInformation not availableInformation not available
Virgin IslandsInformation not availableInformation not available
Source: The Amputee Coalition

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

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 and at the federal level.

2. 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
  • Independently search for a private health insurance plan that fits your needs
  • Use your state’s marketplace or federal healthcare.gov (if your state is not listed below) to enroll in a private health insurance plan.

If you live in any of the following states, your health insurance marketplace is state-based or state-partnered rather than fully federally based. This means that you will need to explore your personal coverage options within your state’s unique 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

3. 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 f 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.

4. What Is the Penalty for Not Having Health Insurance?

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

5. 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.

PremiumsPremiums 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.
DeductibleA 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.
CoinsuranceCoinsurance 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.
CopayA 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 MaximumsOut-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 ExclusionsInsurance 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 ProfessionalsIt 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!

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 current 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.

Additional Resources

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 estimate your out-of-pocket costs, use the National Health Council’s Putting Patients First cost calculator.

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.

To learn more about health insurance coverage for American Indians and Alaska Natives, visit healthcare.gov/american-indians-alaska-natives.

To learn about insurance details specific to individuals with a disability, visit nationaldisabilitynavigator.org.

For more information about how to navigate the health insurance system as a person living with limb loss, you can also order the Amputee Coalition’s resource guide, Insurance Coverage and Reimbursement: How to Be Your Own Advocate.


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.

National Limb Loss Resource Center, a program of the Amputee Coalition, located at 900 East Hill Ave., Suite 390, Knoxville, TN 37915 | 888/267-5669

© 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.