Affordable Care Act enrollment has Dec. 15 deadline
Time is running out to sign up for a health insurance plan through the marketplaces set up by the Affordable Care Act.
Typically, people buying coverage through the marketplace cannot get health insurance through work and don’t qualify for coverage through Medicaid or Medicare.
They include self-employed business owners, gig workers and early retirees.
Consumers have until Jan. 15 to enroll in a marketplace plan. But if they want coverage to start Jan. 1, they must choose a plan by Dec. 15.
More than 84,000 people in Wisconsin signed up for a plan in the first four weeks of open enrollment, in November, according to recently released federal data.
Consumers shopping for plans on the marketplace may notice changes this year, including higher premiums, changes to their plan’s coverage and fewer plan options.
Some health insurance companies pulled out of the marketplace in parts of the state, leaving consumers with fewer choices and forcing some members to switch plans.
Here are some tips for signing up for a plan through the marketplace.
Most people will qualify for financial help
Most consumers shopping on the marketplace will qualify for a subsidy that makes their plan cheaper.
“Many people are expecting to have to pay full price when they should not and do not,” said Tina Marshalek, a health insurance navigator with Covering Wisconsin, a state program that helps people sign up for coverage.
The subsidies come in the form of tax credits and lower the cost of a plan’s monthly premium.
During the pandemic, Congress increased the subsidies. Those increases are to expire at the end of the year, in which case the subsidies will return to their lower, pre-pandemic levels.
Households making less than four times the poverty level, or $62,600 for an individual and $128,600 for a family of four, will qualify still for a tax credit.
But those who earn more than four times the poverty level will no longer qualify for that financial help.
Congress may step in and choose to extend the subsidies beyond December at the higher levels. But a deal has yet to materialize and may not come together before year’s end.
Consider your medical cost estimates
Marketplace plans are divided into categories: bronze, silver, gold and platinum.
Generally, bronze plans have cheaper monthly premiums, but include higher deductibles and other out-of-pocket costs.
Gold and platinum plans are generally more expensive upfront, but have lower deductibles for consumers to pay before the insurer starts paying.
A person who doesn’t expect to go to the doctor much next year might consider buying a cheaper bronze plan. Marshalek cautioned there’s a risk of high out-of-pocket costs in the event of a serious accident or life-threatening diagnosis.
For someone who needs a lot of specialty care or sees the doctor frequently, it’s important to review the costs of that care, which can be billed differently, Marshalek said. She advised considering plans with lower out-of-pocket maximums.
Make sure doctor is in-network, meds covered
It is important to check if your doctors are in-network and your medications covered when looking for the right plan.
Marshalek said to use the filtering tools when browsing plans on the Healthcare.gov website to check if your doctor is in-network and your prescriptions covered. You can check for your doctors by clicking the “add filters” button, then the “add providers” button.
She advised double checking a plan’s drug formulary, or list of covered prescription drugs, to see on what tier each of your prescriptions is billed. Drugs that are covered but listed on different tiers may have different costs and may require different cost-sharing.
“Even if your prescription is a generic, sometimes generics are divided into preferred and non-preferred, and the cost difference can be noteworthy,” Marshalek said.
Get help from a health insurance navigator
Navigator programs were created under the Affordable Care Act, to provide free, impartial help signing up for health insurance.
Navigators can be reached by calling Covering Wisconsin, the state’s navigator program, at 877-942-6837. To set up an appointment with a navigator, you may visit coveringwi.org/enroll.
It helps to work with a navigator to explore your options, especially if you find yourself in a new situation where you may be facing higher costs or no longer qualify for financial help, Marshalek said.
Other enrollment assisters, such as certified application counselors or insurance brokers, also help.
Estimate your 2026 income as close as possible
Applicants will provide an estimate of their 2026 gross income when applying for coverage through the marketplace, Marshalek said.
Anyone renewing a current plan or switching plans on the marketplace should update their application to reflect their expected income for next year.
The income estimate is used to determine how much financial help you receive.
Marshalek advised being as precise as possible. If an applicant ends up making more than they estimated, they may have to pay money back when they file their taxes.
She also advised updating your application throughout the year if your income changes at any point.
What if I get insurance through work?
You may buy a plan through the marketplace, even if your employer offers coverage.
But to be eligible for subsidies, the employer-offered coverage must be considered unaffordable.
If the monthly premium for the cheapest plan would cost you 9.96% or more of your household income, it’s considered unaffordable.
