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 insurance department may be able to help, depending on the problem.
During open enrollment or a special enrollment period, a broker or Navigator can help you enroll or determine whether it’s in your best interest to make a plan change. You can also reach out to the exchange directly, or an enhanced direct enrollment partner.
As of 2024, 32 states use the federally-run HealthCare.gov as their exchange platform, while 18 states and DC run their own exchanges. In most states, open enrollment runs from November 1 to January 15. And special enrollment periods can be available at any time of the year, when a person experiences a qualifying life event.
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.
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 32 states – is outlined here. If you’re in Washington, DC, or one of the other 18 states with state-based Marketplaces, your exchange will have its own process by which you can appeal a decision that the Marketplace makes.
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.
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. If you used a broker to enroll, they will be able to help you with the process of filing an appeal and contacting the state insurance department, if necessary.
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 if you just stop paying the premiums. But if you were receiving a premium subsidy, the termination date will then 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. Plans cannot be retroactively canceled with a premium refund in situations where a person forgot to cancel their coverage.
(The federal government has proposed a rule change for 2025 and future years that would allow for the retroactive termination of Marketplace coverage if the enrollee becomes eligible for backdated Medicare. 1 But even if this is finalized, it would not allow for retroactive termination of Marketplace coverage when a person forgets to cancel their coverage when they transition to Medicare, or doesn’t realize that they need to do so.)
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.
