Department of Human Services

Making Health Insurance Make Sense August 2014

Answers to Some of the Most Commonly Asked Questions

August 1, 2014 | 4 min reading time

This article is 8 years old. It was published on August 1, 2014.


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Q:  When is the next Open Enrollment Period for Medicare beneficiaries and also for consumers interested in getting health insurance through the new Health Insurance Marketplace?

A:  Each year, Medicare beneficiaries have a chance to make changes to the way they get their Medicare and to their Medicare prescription drug coverage for the following year. Medicare open enrollment is every year from October 15–December 7 and any changes made will take effect on January 1.  During this time, Medicare beneficiaries can change from Original Medicare to a Medicare Advantage Plan, change from a Medicare Advantage Plan to Original Medicare, switch from one Medicare Advantage Plan to another Medicare Advantage Plan, and join for the first time or switch from one Medicare Prescription Drug Plan to another Medicare Prescription Drug Plan. Medicare beneficiaries can also drop their Medicare prescription drug coverage completely.  Medicare beneficiaries can either call 1-800-633-4227, Medicare's national toll-free helpline which is available 24 hours a day, seven days a week, or visit during Open Enrollment to make these changes.

Besides Open Enrollment for Medicare beneficiaries, other consumers can apply for health insurance through the new Health Insurance Marketplace during the next open enrollment period.  The next open enrollment period for the Marketplace is November 15, 2014 through February 15, 2015.  The Health Insurance Marketplace, which is a part of the Affordable Care Act, ACA, is a new way for those without health insurance to find health coverage from private health insurance companies that fits their budgets and their needs.  The ACA says that individuals of all ages, including children, have to have minimum essential health insurance coverage, as those without health insurance cause insurance premiums to rise for those who do have health insurance, when those without health insurance utilize the health care system.  The only exceptions for not having health insurance after 2014 are for those who qualify for an exemption such as making too little to file income taxes. Consumers who do not have minimum essential health insurance or who do not qualify for an exemption from it, will have to pay a yearly shared responsibility fee for not having insurance, when they pay their taxes for the year, which will start with the 2015 tax season.  The fee for the first year is 1% of a person's income for the year or $95 per person, whichever is higher. It is half the amount for children and the fee will increase every year up to 2.5% of a person's income or $695 per person, whichever is higher. And the bottom line is paying the fee does not give you health insurance coverage, so one still won't have peace of mind coverage if and when they need health care if they don't enroll in health insurance.  The good news is that the majority of consumers who signed up for health insurance the first year through the Marketplace qualified for help with paying their monthly premium. The Health Insurance Marketplace can potentially save consumers thousands of dollars in hospital and/or doctor bills.  More than 8 million consumers enrolled in the Health Insurance Marketplace during the initial enrollment period that ended March 31.

Q:  Can consumers apply for health insurance through the Health Insurance Marketplace outside of the open enrollment period every year?

A:  Yes, in limited instances.  Even though open enrollment is over, consumers may still have options to get health coverage this year and every year outside of open enrollment through the Health Insurance Marketplace. After Open Enrollment, each year, you can enroll in a private health plan through the Marketplace only if you qualify for a special enrollment period. To help consumers understand their options, the Centers for Medicare &Medicaid Services, CMS launched a new screening tool which can be found at: or consumers can call the health insurance marketplace call center which is: 1-800-318-2596.

Generally the circumstances that qualify someone for a special enrollment period include:

  • Losing health coverage in the last 60 days OR expecting to lose it in the next 60 days. Below are most examples of coverage loss that qualify consumers for a special enrollment period (voluntarily giving up coverage does not qualify someone for a special enrollment period):
  • Lost coverage due to divorce
  • Policy or plan year ended for policy you bought yourself
  • COBRA coverage expired which is a continuation of employer insurance once you leave a job
  • Turned 26 and aged off a parent's health plan
  • Lost eligibility for Medicaid or CHIP
  • Experiencing any of the following in the past 60 days: Changes in household size:
  • Got married
  • Had a baby
  • Got divorced
  • Adopted a child or had a child placed with you for foster care
  • Death
  • Changes in circumstance:
  • Moved to a new address
  • Had a change in income
  • Changes in status:
  • Gained citizenship or lawful presence in the U.S.
  • Released from incarceration (prison or detention)
  • Or, if one is a member of a federally recognized tribe, or an Alaska Native corporation shareholder.

If these changes qualify someone for a special enrollment period, in most cases you have 60 days from the life event to enroll in new coverage. If the changes qualify someone for more or less savings, such as more or less of the advanced premium tax credit it's important to make adjustments to your application as soon as possible.

Reporting these changes will help you get the proper type and amount of financial assistance so you can avoid getting too much or too little in advance.

If you get too much of the premium tax credit in advance, than you might get a smaller tax refund starting in 2015 than you expected, or even owe money that you did not expect to owe.

It is important that you do not report these changes by mail. You can report these changes 2 ways:

  • Online. Log in to your account (or create an account if you don't have one). Select your application, then select "Report a life change" from the menu on the left.
  • By phone. Contact the Marketplace Call Center at 1-800-318-2596 (TTY: 1-855-889-4325),

The only way to know for sure if someone qualifies for a special enrollment period in the Health Insurance Marketplace is to fill out an application.

Finally, insurance companies, agents, brokers, and online health insurance sellers may sell private health plans outside the Marketplace and outside Open Enrollment that count as minimum essential coverage. However, it is important to note that if someone purchases a plan outside of the Marketplace, they can't find out about and get the premium tax credits or lower out-of-pocket costs that are only available through the Marketplace.


Department of Human Services

City of St. Louis