Open Enrollment

Open enrollment is in the fall with the goal of having coverage start on January 1^st and end on December 31^st. Obamacare and Medicare both use this term.

Before Obamacare

Prior to the Affordable Care Act there wasn’t an open enrollment period for people trying to purchase health insurance on their own. You could apply for insurance anytime but you faced the possibility of being rejected due to pre-existing conditions. Plans would start at different times of the year.

Obamacare and open enrollment

The Affordable Care Act established an open enrollment period. The concept was modeled after the Medicare open enrollment setup, but with different dates. During this time, insurers are required to accept anyone regardless of health condition.

♦ People receiving health insurance through their employer also have an open enrollment period.

The time varies depending upon the employer but it is usually in the fall and usually lasts only a couple weeks. It is at this time that employees can freely change between plans offered by their employer.

Open enrollment does not affect people applying for Medicaid or the Children’s Health Insurance Program (CHIP). Applications can be made at any time during the year for these programs.

When is open enrollment?

The time will depend on your situation:

• Marketplace open enrollment → November 1^st — January 15^th , 2025

• February 1: Coverage starts for those who enroll in or change plans December 16^th through January 15^th and pay their first premium.

Most states end on January 15^th, the states that run their own exchanged can decide their own dates.

• Medicare open enrollment → October 15^th — December 7^th

• Employment-based open enrollment – set by employer (usually in the fall)

Through the Marketplace

For 2025 coverage

• Note: states that are running their own exchanges have the option to extend the enrollment period beyond January 15^th, but are not required to do so.

You can still enroll outside of these dates if you have a special situation.

Once you sign up for a plan, you are locked into that plan until the next open enrollment period.

Exceptions are available for some special cases that may permit you to qualify for a Special Enrollment Period.

♦ To be eligible, you have to have certain life events, like getting married, having a baby, or losing other health coverage.

Open enrollment is the time you should compare your current plan with new plans. You should consider what your healthcare needs may be next year.

• If you expect to use more medical services, have surgery or expensive tests, you may want to look more seriously at lower deductible plans for next year.

All plans change some each year. Medicare recipients have gone through this process every year since the introduction of managed care plans into the Medicare mix.

Plans purchased through the Marketplace need to be looked at carefully every year just like Medicare recipients do with their plans.

♦ Insurance companies are always changing their plans to include some new ways to shift costs to the consumer.

Sometimes cost increases are obvious, like a premium increase. But often it is subtle or vaguely explained.

It is so important that you read the plan's Summary of Benefits Coverage (SBC) carefully.

♦ Understand which costs will go up and work to find the plan that affects you the least.

• Will the premium increase?

• Will copays and coinsurance increase?

• Will the deductible increase? Can you afford to pay it?

• What will the out-of-pocket maximum be?

• Especially, look to see if emergency room costs will be changing?

• Most plans are shifting ER costs to the deductible.

• Will it cost more for testing and outpatient procedures?

• Will the plan's network change? Is your closest hospital in it?

• Is there an urgent care facility near you?

• Will prescription costs change? Will there be a separate deductible?

• Expensive medications should be compared with other plans.

Do not qualify for Special Enrollment Period

If you do not qualify for a SEP, you may be able to apply for a short-term health insurance plan in some states.

Short-term health insurance coverage can be purchased outside of the open enrollment period. Short-term coverage is limited.

• You may purchase up to four months during a 12-month period.

Short-term health insurance plans may work for healthy people, as they will not cover pre-existing conditions, and may be subject to medical underwriting. Anyone with a health condition needs to look at all other options before enrolling in a short-term plan.

States that don’t offer short-term health plans include:

California, Colorado, Connecticut, Hawaii, Maine, Massachusetts, New Jersey, New Mexico, New York, Rhode Island, Vermont, and Washington state.

♦ If you do not qualify for a SEP and decide not to apply for a short-term health plan, you will have to wait until Open Enrollment 2026 begins in the fall 2025.

Medicare open enrollment period

This should not be confused with the time for enrolling in Medicare.

The time when you can first enroll in Medicare is called: Initial Enrollment Period (IEP).

♦ You have a 7-month Initial Enrollment Period to sign up for Part A and/or Part B.

• It starts 3 months before your 65th birthday, includes the month of your birthday and ends 4 months after your birthday.

If you don’t sign up for Part A and/or Part B when you are first eligible, and you aren’t eligible for a Special Enrollment Period, you need to wait and sign up during what is called: General Enrollment Period, which is January 1^st – March 31^st of each year.

Note: situations that will trigger a Special Enrollment Period for Medicare recipients are different than the special enrollment requirements related to the Affordable Care Act and Marketplace coverage.

♦ Open enrollment period for Medicare is always October 15^th through December 7^th each year. During this time you can —

• Switch from Original Medicare to a Medicare Advantage plan

• Change to a new Medicare Advantage plan

• Switch back from an Advantage plan to Original Medicare

• Change your Part D prescription drug plan

It is during this time that you should re-evaluate your situation. Every Advantage plan is required to send you a notice of changes planned for the next year. The changes will shift more costs to you. Find out which costs will go up.

• Will the premium increase?

• Will the copays and coinsurance increase?

• Especially, look to see if emergency room costs will be changing? Most plans have had a $75 to $100 copay.

• Will it cost more to see the family doctor?

• Will the hospital closest to you still be in the plan’s preferred network?

• Will prescription costs change?

• Expensive medications should be compared with other plans.

Employer-based open enrollment

Just like other open enrollment periods, this is the only time when you can change health plans.

Your employer decides the time. Most companies have settled on the fall so plans can start January 1^st and end December 31^st.

Generally, employer provided plans are limited in the number you have to consider. Many people end up selecting a plan and then simply letting it automatically renew.

As health care costs keep increasing more and more employers are trying to encourage their employee to utilize Consumer-Drive Health Plans and / or Health Savings Accounts. These need to be studied very carefully.

Once you select a plan, you are locked in until the next open enrollment period.

Special enrollment periods may be available but your employer sets the requirements, which may not be so flexible if you company’s plan is self-funded.