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Who can help if I have a problem with my ACA-compliant coverage or exchange enrollment?

If you run into problems with the exchange enrollment process, start by contacting your broker or health insurance marketplace. | Image: fizkes / stock.adobe.com

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Q.  Who should help me when I’m having a problem enrolling through the exchange or using my ACA-compliant coverage?

A: In an ideal world, health insurance enrollments, rules, and claims processing would always be straightforward and clear. But in the real world, it’s not always that simple. Some scenarios are more complicated than others, and sometimes the problem is just plain human error.

Here’s a quick summary of what to keep in mind in case you run into troubles with the enrollment or disenrollment process, or with using your self-purchased ACA-compliant health plan.

We’re focusing mostly here on plans that are purchased in the exchange / marketplace. But if you buy an individual major medical plan outside the exchange, it will also be ACA-compliant. If you run into troubles with an off-exchange plan, you’ll usually just need to reach out to your broker or directly to the insurance company. And in some cases, your state’s department of insurance may be able to help, depending on the problem.

Who can help me enroll or make a plan change during the COVID-related enrollment period in 2021?

The COVID-related enrollment period in 2021 is a unique circumstance. In normal years, there’s one open enrollment period (a month and a half long in most states) and enrollment or plan changes outside of that window are limited to people who experience a qualifying event. But in 2021, to address both the COVID pandemic and the enhanced premium subsidies created by the American Rescue Plan, the federal government is giving people until August 15, 2021 to enroll in a plan through HealthCare.gov, which is the exchange that’s used in 36 states as of 2021. This window is also open to people who already have coverage through the marketplace and would like to make a plan change, and qualifying events are not necessary in order to use this enrollment window.

DC and 14 states run their own exchanges; all of them have announced some sort of COVID-related enrollment period, although they have varying deadlines and not all of them are as flexible as the window that’s being offered on HealthCare.gov (ie, some are limited only to people who don’t already have coverage through the exchange, although that might change as time goes on, in order to give current enrollees an opportunity to make a plan change to better utilize the ARP’s enhanced subsidies).

If you normally work with a broker, that person can help you enroll or determine whether it’s in your best interest to make a plan change and help you do so if that option is available in your state. You can also reach out to the exchange directly, or an enhanced direct enrollment partner. Enrollments completed during the COVID-related enrollment window will generally take effect the first of the following month.

Who should I contact if I have problems enrolling in a health plan through the marketplace?

If you run into problems with the enrollment process, start by contacting your health insurance marketplace. HealthCare.gov and the state-operated exchanges have systems in place to help if your special enrollment period eligibility has been denied, or if your subsidy application process resulted in a financial assistance determination that doesn’t seem correct.

How can I appeal an ACA marketplace decision?

There are a variety of scenarios in which you can appeal the marketplace’s decision, and get the appeals process expedited. The appeals process used by HealthCare.gov – the enrollment platform used in 36 states – is outlined here. If you’re in Washington, DC, or one of the other 12 states with state-based marketplaces, your exchange will have its own process by which you can appeal a decision that the marketplace makes.

  • If you believe you’re eligible for a special enrollment period and the marketplace says you’re not, you might find some helpful resources in our guide to special enrollment periods. In most cases, we link to the applicable federal regulations, which may help you when you’re providing supporting documentation for your appeal.
  • If a financial assistance eligibility determination doesn’t work out the way you expected, our guide to premium subsidies might be useful in understanding what’s happening. We also have a detailed explanation of how premium subsidy amounts are determined based on the percentage of your income that you’re expected to pay for your coverage.

What should I do if the marketplace or my insurer has incorrect information about me?

There are various situations in which you might find that some sort of glitch has arisen and your information has not been received in a timely manner by the exchange – or perhaps incorrect information has been transmitted to your insurer. This can result in the erroneous termination of premium subsidies – or even your entire health plan.

If you used a broker to help with your enrollment process, they should be your first call in situations like this, as they’ll be able to work with both the marketplace and the insurer to sort out the problem. (Regardless of the situation, your broker should be your first call if you run into troubles with the marketplace or your insurer. If your issue can be resolved, your broker will be able to help you.)

If you enrolled on your own, you’ll need to contact the marketplace and the insurer, and keep careful records of the calls and any appeals that you submit. Make sure you get an incident/tracking number for any calls, if available, or note the name of the person who helps you.

Who can help if I have problems with my ACA-compliant coverage?

If you’re already enrolled and you’re having trouble with your coverage, there’s a different appeals process you can use. If your insurer isn’t paying for your medical care and you believe they should be, you can file an internal appeal, which just means your health insurer will take a closer look at your claim – including any additional documentation you and your doctor submit with the appeal. If that doesn’t work, you also have the option to request an independent external review.

All individual and family ACA-compliant health plans are regulated by state insurance departments, which means the insurance commissioner in your state oversees the insurance company to make sure they’re complying with state and federal rules. If you’re having a problem with your health insurer, you can reach out to your state’s insurance department for help.

How can I make changes to my ACA health coverage or cancel it?

If you’re enrolled in an off-exchange health plan, you can contact your insurer directly for changes such as disenrollment from the plan, changing your address or adding a newborn child to your plan. But if you have a plan through the exchange, you’ll need to make those kinds of changes by contacting the exchange. Once you update your information with the exchange, it will transmit the new data to your insurer.

One point that sometimes causes confusion is the need to terminate your coverage when you transition to another plan, including Medicare. Your individual-market plan will not automatically terminate when you obtain employer-sponsored health insurance, move to a new area, or turn 65.

Your plan will terminate when you stop paying the premiums. But if you were receiving a premium subsidy, the termination date will be a month after the last premium you paid, and you’ll have to repay the IRS for the subsidy that was paid on your behalf during that extra month.

If your monthly premiums are automatically drafted from your bank account or charged to your credit card, you’ll need to be especially vigilant about canceling your coverage when you transition to a new plan. There is no mechanism that allows a plan to be retroactively canceled with a premium refund in situations where a person forgot to cancel their coverage.


Louise Norris is an individual health insurance broker who has been writing about health insurance and health reform since 2006. She has written dozens of opinions and educational pieces about the Affordable Care Act for healthinsurance.org. Her state health exchange updates are regularly cited by media who cover health reform and by other health insurance experts.

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Paul W. Seddon
Paul W. Seddon
3 months ago

I am dealing with the insurance marketplace and trying to correct a error on their part in which I contacted them on September 03,2021 to withdraw
From coverage due to enrolling in Medicare! Leaving my wife with coverage through them! Unfortunately what I thought was termination of my coverage fell into the timeframe of the government recovery act which paid my part of
Premium so I never saw a premium notice and assumed the policy was canceled! Also at the time
I was also dealing with the end stages of my wife’s
stage 4 cancer! I had no idea I still had coverage until I received a letter on January 6 stating I had been automatically unrolled in coverage for me
And my now deceased wife and owed a premium!
I contacted theMarketplace who we had originally
Got our coverage through expecting to resolve the issue but on got representatives who wanted to enroll me in another plan not help me with the
Past termination of my plan!

Louise Norris
Editor
3 months ago
Reply to  Paul W. Seddon

Paul, I’m really sorry you’re dealing with this issue, and my condolences on the passing of your wife.

The marketplace representatives shouldn’t be trying to enroll you in another plan, given that you have Medicare. The situation you’re describing is complicated, and there are a lot of factors involved. It’s likely that your subsidy would have covered the full cost of your premiums when you were both enrolled, but not the full cost of just your wife’s plan after you switched to Medicare (this is a common scenario: https://www.verywellhealth.com/obamacare-subsidies-change-with-family-size-4065153)

Since they didn’t terminate your marketplace coverage when you first requested it, the problem is that the subsidy was still being paid on your behalf for the final months of the year when you had Medicare as well. Those subsidies will have to be repaid on your tax return unless you can get the marketplace to retroactively cancel your coverage and return the subsidy on your behalf so that it doesn’t show up on the tax form that the marketplace sends to you and to the IRS (at this point, they would need to issue a corrected form, since those forms have likely already been generated for 2021 coverage).

The other problem is that it sounds like the marketplace plan you had was auto-renewed for 2022? You’ll need to contact the marketplace again and ask them to escalate this to a supervisor who can get involved and try to straighten it out for you.

Martha
Martha
3 months ago

I am dealing with total incompetence from marketplace employees. My husband called to remove himself from our insurance on Feb 28 due to him enrolling in Medicare March 1. Instead they cancelled our policy immediately for both of us and started a new policy for myself. Now he has no insurance for a month and I have a new policy and a new deductible to satisfy. We have called four times to have this corrected and get nothing but the run around.

Louise Norris
Editor
3 months ago
Reply to  Martha

I’m sorry you’re dealing with this – definitely a frustrating situation. Have you escalated it to a supervisor at the marketplace? If not, we recommend that you do that. We would also recommend that you reach out to your health insurer directly, so that they have notes about this situation in their records.

Last edited 3 months ago by Louise Norris
Amanda
Amanda
3 months ago

Hi I am having a similar issue. Cancelled coverage august 2019 and somehow I was reenrolled in 2020, 2021 and 2022 without knowing. I realized when my taxes were rejected. Called and they don’t have record of my cancellation and there was apparently an automatic enrollment and no notices sent by email to me (which is my communication preference). So I had no idea. To make matters more complicated, I was married in 2020 and have been on my husbands insurance since. So I called and they forwarded my case but told me I would most likely have to pay the $$ back. I am trying to find out why the insurance company isn’t responsible for paying the funds back and/or what else I can do. It seems unfair since I had no clue this was occurring.

Louise Norris
Editor
3 months ago
Reply to  Amanda

I’m sorry you’re in this situation. Unfortunately, it’s ultimately the tax filer’s responsibility to make sure that their premium tax credit is correctly reconciled, even though the advance tax credit was paid to the insurance company throughout the year. It sounds like your 2020 tax return just recently got rejected, alerting you to the problem? The insurance company and the marketplace should have been sending you notifications of your coverage renewals via US mail, and you should have received a 1095-A for 2020 and 2021 as well. You’ll want to check with the insurer and the marketplace to confirm that those documents were sent, and what address they used.

Depending on the documentation you have in terms of your cancellation request, as well as mitigating circumstances (eg, an address change with no forwarding address), your best chance is going to be trying to get the insurance company to retroactively cancel your coverage. I will warn you, however, that it’s extremely uncommon for an insurance company to do that for more than a few months of coverage; getting your plan retroactively canceled to August 2019 is very unlikely.

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