Steps in the Enrollment Process
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Areas Where Consumers Will Need Help |
1. Learning that coverage is available |
- Getting information about new coverage options, how to apply, and how to obtain assistance.
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2. Obtaining an application |
- Finding community-based locations where they can either use computers to apply for coverage online or obtain a paper application.
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3. Determining whether to apply for insurance affordability programs |
- Understanding insurance affordability programs (premium tax credits and cost-sharing reductions for qualified health plans, Medicaid, CHIP, and the Basic Health program) to the extent needed to determine whether the applicant or a family member may be eligible for these programs.
- Gathering the information needed to apply for these programs.
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4. Describing household members |
- Providing information on all family members who are part of the household for the purpose of filing taxes. This may be more challenging for consumers who have not filed taxes previously, who live separately from dependents or spouses, who have shared custody arrangements, or who are used to the current application for Medicaid or CHIP.
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5. Confirming or reporting correct income information |
- When using an online application, adjusting pre-populated calculations of current and projected household income that appear to be incorrect.
- Identifying recent or expected changes in income or family size (marriage, divorce, birth, adoption, job change, etc.) to provide the most accurate projection of income and family size for the current tax year.
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6. Providing information about an offer of job-based coverage |
- Collecting information on coverage and its affordability for job-based plans using the lowest-cost plan the employer offers. (HHS may develop a template form that employers can use to provide required information to employees.)
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7. Submitting supplemental documentation, if needed |
- Gathering and submitting approved forms of documentation within deadlines when information cannot be verified through data matching and when self-attestation is not accepted.
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8. Reviewing eligibility determinations |
- Understanding coverage options for which they or their family members have been determined to be eligible.
- Appealing an eligibility determination that appears to be incorrect.
- Obtaining information about Medicaid coverage for emergency care if a member of the applicant’s household is an eligible non-citizen.
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9. Enrolling in public coverage, if eligible |
- Selecting a managed care plan if the state provides Medicaid or CHIP though managed care organizations.
- Understanding premium requirements for Medicaid managed care plans.
- Completing supplemental sections of the application or supplemental forms to apply for Medicaid under traditional (non-MAGI) rules based on a disability, need for long-term care, or high medical expenses.
- Obtaining coverage through the exchange while waiting for a determination of eligibility for traditional Medicaid.
- Ensuring successful completion of the enrollment process if applications are transferred to a state Medicaid or CHIP agency for a final eligibility determination.
- Coordinating plan choices among individuals in the same household.
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10. Deciding the advance amount of premium tax credits to take, if eligible |
- Understanding the tax credit reconciliation process, the potential tax liability, and the implications for how taxes are filed.
- Assessing how much, if any, of the premium tax credit to take in advance monthly payments to minimize the risk of repayment.
- Understanding when and how to report changes in income and family size.
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11. Selecting a qualified health plan (QHP) |
- Understanding plan features, such as premiums, cost-sharing, and the differences between plans.
- Comparing costs under different coverage tiers based on eligibility for tax credits and cost-sharing reductions.
- Comparing the benefits package in each plan to determine which provides needed services, includes current providers, covers certain prescription drugs, or has other features that are important for the individual or family.
- Enrolling in supplemental coverage, such as a stand-alone vision or dental plan, if needed.
- Coordinating plan choices among individuals in the same household.
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12. Obtaining an exemption from the individual responsibility requirement, if eligible |
- Obtaining exemptions from the individual responsibility requirement if coverage options are unaffordable, or for other allowable reasons.
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