Can I Change My Marketplace Plan During the Year?

The Affordable Care Act (ACA) Marketplace provides a platform for individuals and families to obtain health insurance coverage. While there is an annual Open Enrollment period when anyone can select or change a health plan, circumstances can arise throughout the year that necessitate a change in coverage. Understanding the specific conditions for plan modification outside Open Enrollment is important.

Qualifying for a Special Enrollment Period

Individuals generally cannot change their Marketplace health plan outside of the annual Open Enrollment period unless they qualify for a Special Enrollment Period (SEP). An SEP is a time outside of standard enrollment when consumers can enroll or change existing coverage. This period is triggered by specific life events that cause a change in household, residence, or health coverage status.

Common qualifying life events include changes in household composition, such as marriage, divorce, birth, adoption, or foster care. These events often alter the number of people needing coverage and can affect income levels, making a new plan necessary. Changes in residence, like moving to a new county or state, can also trigger an SEP if the new location falls outside the service area of the current health plan.

Involuntary loss of health coverage (job-based, COBRA, Medicaid, or CHIP) is another frequent trigger for an SEP. However, voluntarily quitting a job or being terminated for cause usually does not qualify. Turning 26 and losing coverage under a parent’s plan, or losing eligibility for student health plans, also qualifies for an SEP.

SEPs typically last 60 days following the qualifying life event. Report the event and select a new plan within this timeframe to avoid a coverage gap. Documentation (marriage certificate, birth certificate, proof of new address, or a letter from a former employer confirming loss of coverage) is often required to verify your qualifying event.

Steps to Change Your Plan Through a Special Enrollment Period

After determining SEP qualification and gathering necessary documentation, report the life event to the Health Insurance Marketplace. Log into your account on HealthCare.gov or your state’s marketplace website. The platform has a section for reporting life changes.

Select the specific qualifying life event. Provide details about the event, such as the date and any relevant information about household members or previous coverage. Upload the required documentation to verify the event.

After successful verification, the Marketplace system will allow you to browse and compare available health plans. Review various plans, considering factors like premiums, deductibles, out-of-pocket maximums, and network providers. Once a new plan is selected, you will proceed with enrollment steps, which may include confirming personal details and setting up initial premium payments.

Review all selected plan details and confirm your enrollment choice. The Marketplace will process the application and send a confirmation of enrollment. It is advisable to keep a record of the confirmation and any policy numbers provided, as this information will be needed for future interactions with your new health insurance carrier.

Understanding Your New Plan and Subsidies

After successfully changing a Marketplace plan through a Special Enrollment Period, understanding the practical and financial implications of the new coverage is important. The effective date of the new plan typically depends on when the qualifying event was reported and the new plan was selected. For instance, if an individual reports a birth and enrolls within 30 days, the baby’s coverage can be retroactive to the date of birth.

A significant consideration when switching plans, even within the same year, is the impact on deductibles and out-of-pocket maximums. Generally, these amounts reset to zero with a new plan, meaning any expenses paid towards these limits under the previous plan do not carry over. This can affect financial planning, particularly if substantial medical costs have already been incurred earlier in the year.

Advanced Premium Tax Credits (APTCs), which help reduce monthly premium costs, may be recalculated when a plan is changed. These subsidies are based on household income and size, as well as the cost of the benchmark silver plan in the individual’s area.

A new plan selection, or any changes in income or household size reported during the SEP process, can alter the amount of APTC received, potentially changing the out-of-pocket premium.

It is also important to verify that current doctors, specialists, and prescription medications are covered under the new plan’s network and formulary. Health plans have different provider networks and drug lists, and switching plans may necessitate finding new providers or adjusting medication regimens.

Regularly updating income information with the Marketplace, even after initial plan selection, is advisable, as significant changes can affect APTC eligibility and prevent potential tax reconciliation issues.