Open Enrollment Period Basics

Open Enrollment for all individual major medical plans is only available once a year; everyone is able to apply during that time. Open Enrollment for 2019 is from November 1 – December 15, 2018. For those who don’t enroll in a plan by December 15, 2018, they will go without coverage in 2019 unless they qualify for a Special Enrollment Period.

2019 Open Enrollment is November 1, 2018 – December 15, 2018. The first date on which 2019 coverage can start is January 1, 2019.

While Open Enrollment is only available once a year, you may be able to purchase insurance at other times through a Special Enrollment Period if you have a Qualifying Life Event. You may also be eligible for special subsidies, but you generally have only 60 days to apply!

Special Enrollment Periods Basics

If you have had a “qualifying life event” (or QLE) you do not have to wait until Open Enrollment to purchase health insurance. The full list of QLEs is here, and here are the four basic categories:

        1. Loss of health coverage: losing coverage from a change in employment, or hitting 26 and no longer being covered under a parent’s plan
        2. Household change: marriage or divorce, adding a family member through birth or adoption, a death in the family
        3. Change in residence: moving to a different ZIP code or county (this can include students), moving to or from a shelter or other transitional housing
        4. Other qualifying events: change in your income that affects the coverage you qualify for, becoming a U.S. citizen, leaving jail or prison
        5. Complex Situations: a serious medical condition or natural disaster kept you from enrolling during Open Enrollment; misinformation or misrepresentation during enrollment; enrollment error; victims of domestic abuse
Important Considerations When Evaluating Health Insurance Options

When comparing plans, you’ll need to consider your health and your financial situation. Finding a balance between coverage and costs can be challenging.

Here are some things to consider:

Do you expect a lot of doctor visits or require regular treatments?
You may be better off with a Platinum or Gold plan that pays for a greater percentage of your care. However, if you are generally healthy and don’t anticipate many healthcare bills, a Silver or Bronze plan may be a better choice. It will pay a lower percentage of your costs when you require care, but the premium will cost you less per month.

What is the lowest cost for your healthcare needs?
The plan with the lowest premium may not provide the best value. When comparing plans, out-of-pocket costs are just as important as premiums. Your costs – like copays and coinsurance – can add up. Deductibles for some plans can amount to thousands of dollars a year. Plans with similar benefits may have varying out-of-pocket costs.

What did you spend last year?
Don’t stick with a health insurance plan out of habit. If you spent more in out-of-pocket medical costs than you had anticipated, you may wish to switch to a policy with more comprehensive coverage. But if you didn’t go to the doctor very often, don’t require many prescriptions, and you have some savings, consider a plan with lower premiums. While the deductibles will likely be higher, even if you visit your primary provider several times, it will probably still be cheaper.

Which type of Provider Network is right for you?
HMOs match you with a primary care provider who is responsible for any referrals you need. EPOs often don’t require referrals, but do require that you choose providers from within a set network. PPOs offer more options by covering out-of-network care. A POS (a mix of an HMO and a PPO) provides access to a variety of doctors, but generally requires a referral to see any kind of specialist. POS plans are typically more expensive than HMO plans, but also provide the most flexibility.

Doctor and hospital networks vary widely among companies and also geographically. If you aren’t attached to a particular doctor, an HMO plan could save you money. However, having more choice of providers can be valuable for some families, especially if you live in a rural area with limited access to healthcare providers.

Are you staying healthy?
You may feel comfortable with a less expensive plan if you practice good health habits. According to a study in the New England Journal of Medicine, preventable illnesses account for 70% of health care costs. The fewer unhealthy behaviors you have, the less frequently you’ll need to visit the doctor, and the less you will spend.

Glossary of Terms

Coinsurance:This is the amount that you are obligated to pay before insurance pays and after you’ve satisfied any co-payment or deductible. Coinsurance is typically expressed as a percentage of the charge for a medical service. For example, if your insurance company covers 80% of the allowable charge for a specific service, you may be required to cover the remaining 20% as coinsurance. Because there is no upper limit on coinsurance, you could end up paying a significant amount if your medical expenses are high.

Co-payment: A fee you pay every time you use a given service, like a doctor’s visit, prescription refill, or hospital stay. Plans sometimes refer to this payment component as an “office visit.”

Deductible:  The dollar amount (usually per calendar year) you need to pay for medical expenses before the insurance kicks in. Not all health insurance plans require a deductible. As a general rule (though there are many exceptions), HMO plans typically do not require a deductible, while most PPO plans do.

Exclusive Provider Organization (EPO): As a member of an EPO, you can use the doctors and hospitals within the EPO network, but cannot go outside of the network for care.

Exclusions: Not all services are covered. You are generally expected to pay the full cost of non-covered services out of your own pocket.

Health Maintenance Organization (HMO):  Requires a visit to your PCP prior to visiting a specialist. Less expensive, but less flexible. You must use in-network physicians.

Primary Care Physician (PCP): The family doctor you often need to contact before you can see a specialist. Often referred to as a “gatekeeper.”

Point of Service Plan (POS):  Falls between an HMO and a PPO. The variety of plans is infinite, but they are usually moderately priced and flexible; you must visit your PCP for in-network, but you can go in or out of network (for an added cost).

Preferred Provider Organization (PPO):  Often the most flexible managed care insurance plan, but also the most expensive. You can go to any doctor you choose or go to in-network doctors for less money. No visit to your PCP is required before visiting a specialist. PPO plans often require co-payments or coinsurance, and almost always have an annual deductible.

Premium: Your payment for insurance coverage.


Most people are eligible to buy individual major medical insurance that is compliant with the Affordable Care Act. Alumni/ae, family, and friends who meet the following requirements may apply:

        • You must live in the United States.
        • You must be a U.S. citizen or national (or be lawfully present).
        • You cannot be currently incarcerated.

If you have Medicare coverage, you are not eligible.

In all 50 states and DC, the Affordable Care Act mandates that you have health insurance.

If any of the following circumstances applies to you, then you should consider purchasing Individual Major Medical Insurance:

        • You desire comprehensive individual major medical insurance that is compliant with the Affordable Care Act
        • You work part- or full-time without employer-sponsored health insurance
        • You are self-employed, a freelancer, or a consultant
        • You qualify for a Special Enrollment Period because you have experienced a Qualifying Life Event
        • You are temporarily without coverage but reside in a state where Short Term Medical Insurance is not available.*

For the 2019 plan year, the Shared Responsibility Payment (“mandate,” “penalty”) no longer applies. You don’t need an exemption for 2019 or beyond.

* Short term medical insurance is not available in MA, NJ, NY, or VT. In addition, short term medical insurance is not ACA-compliant.

Open Enrollment for 2019 is from November 1 – December 15, 2018. During that period, you can obtain coverage beginning as soon as January 1, 2019.

For those still seeking individual major medical health insurance for 2018, Open Enrollment ended last December. You must qualify for a Special Enrollment period to obtain coverage for the remainder of this year.

During Open Enrollment, everyone can purchase a new health insurance policy, renew current coverage, or switch policies. Only those individuals who have a Qualifying Life Event may purchase individual major medical outside of Open Enrollment.

Coverage purchased during Open Enrollment for 2019 (November 1 – December 15, 2018) can begin as soon as January 1, 2019.

Open Enrollment for 2018 has ended.

If you experience a Qualifying Life Event and become eligible for a Special Enrollment period, you may purchase coverage outside of Open Enrollment. Qualifying life events include marriage or divorce, birth or adoption of a child, gaining citizenship, changing residences, changing dependent status after turning 26, returning from active military duty, or losing insurance. You might also meet the requirements for a Special Enrollment period if you tried to enroll during Open Enrollment, but couldn’t for technical reasons.

If you qualify, your Special Enrollment Period ends 60 days after the qualifying event that triggered it.

If you are eligible for the following government-sponsored programs, enrollment is available at any time of year:

  • Tricare (for active and retired military)
  • Medicaid and the Children’s Health Insurance Program
  • Indian Health Service/tribal program

Individual health plans are categorized into four standardized levels of coverage: Platinum, Gold, Silver, and Bronze.*

All plans provide the same minimum essential health benefits, cover pre-existing conditions, and provide free preventive services. Some plans may offer additional coverage, but no plans in the marketplace can offer less. The most significant difference among the plans is how you and the plan share the costs of your care:

  • Platinum – Plan pays 90%, you pay 10%
  • Gold – Plan pays 80%, you pay 20%
  • Silver – Plan pays 70%, you pay 30%
  • Bronze – Plan pays 60%, you pay 40%

Based on averages

* Catastrophic plans are also available to those under age 30 and those with hardship exemptions. These plans are designed to protect you from the expense of serious accidents or illnesses. These plans pay less than 60% of the costs of your care.

An “off-exchange” plan refers to a health insurance policy that is not available for purchase on a federal or state exchange. Both on- and off-exchange individual health plans must satisfy Essential Health Benefits coverage requirements and follow the same standardized levels of coverage as those sold on Private Exchanges.

Some plans are offered by a given carrier both on- and off-exchange, however, subsidies are only available for on-exchange plans. Subsidies are never offered on off-exchange plans.

You can compare plan options, view a free quote without obligation, and apply online.