How will Enrollment in Health Insurance Exchanges Work?

Exchanges will allow for direct comparisons of private health insurance options based on price, quality and other factors and will coordinate eligibility for premium tax credits and other affordability programs.

The Affordable Care Act (ACA) calls for the creation of state-based competitive marketplaces, known as Affordable Health Insurance Exchanges (Exchanges), for individuals and small businesses to purchase private health insurance. According to the Department of Health and Human Services (HHS), the Exchanges will allow for direct comparisons of private health insurance options based on price, quality and other factors and will coordinate eligibility for premium tax credits and other affordability programs.

ACA requires the Exchanges to become operational in 2014. Enrollment in the Exchanges for eligible individuals and small businesses is expected to begin on Oct. 1, 2013.

Individual Eligibility

An individual will be eligible for enrollment in a “qualified health plan” (QHP) through an Exchange if he or she:

• Is a citizen, national or non-citizen lawfully present in the U.S., and is reasonably expected to remain so for the entire period for which enrollment is sought;
• Is not incarcerated; and
• Resides in the state covered by the Exchange.

Each Exchange will determine whether an individual meets the eligibility standards for enrollment. After the Exchange determines eligibility, the Exchange will provide the individual with a timely, written notice of his or her eligibility determination.

Enrollment Periods

The ACA requires Exchanges to have an initial open enrollment period, an annual open enrollment period and certain special enrollment periods. Individuals will only be able to enroll in a QHP through an Exchange during one of the permitted enrollment periods.

Initial Enrollment Period

The initial open enrollment period is expected to run from Oct. 1, 2013, through March 31, 2014. Coverage must be offered effective Jan. 1, 2014, for qualified individuals whose QHP selections are received by the Exchange on or before Dec. 15, 2013. For selections received between the first and 15th day of January, February or March 2014, coverage must be provided effective the first day of the following month. For those received between the 16th day and the last day of any month between December 2013 and March 31, 2014, the Exchange must ensure coverage is effective the first day of the second following month.

Special Enrollment Periods

Qualified individuals and enrollees may be allowed a “special enrollment period” under certain circumstances (such as marriage or birth of a child), during which they could enroll in QHPs or change enrollment from one QHP to another. Each special enrollment period will be 60 days from the date of the triggering event. The effective date of any coverage elected during a special enrollment period follows rules similar to those applicable during initial enrollment. This means that coverage would be effective as of the first day of the month for elections made by the 15th of the preceding month, and on the first day of the second following month for elections made between the 16th and the last day of a given month. However, coverage would be effective on the date of birth, adoption or placement for adoption, when that is the special enrollment triggering event.

Annual Enrollment Periods

The annual enrollment period for 2015 and subsequent years will begin October 15 and extend through December 7 of the preceding calendar year. Starting in 2014, the Exchange must provide advance written notice to each enrollee about annual open enrollment no earlier than September 1, and no later than September 30.