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6 must-dos for the toughest open enrollment yet

Bipartisan Obamacare subsidies fix?
Trump backs away from bipartisan Obamacare subsidies plan 02:44

Open enrollment for people shopping for 2018 health insurance through the Obamacare exchanges begins on Wednesday, Nov. 1. For most consumers, it promises to be an even more frustrating event than usual.

Fewer choices in the exchange marketplace and recent cutbacks from the Trump administration, including ending important reimbursements and slashing consumer support, make for an uncertain market and confused customers.

People are fending for themselves at a time when they seem more perplexed than ever. Almost 76 percent of Americans don't know when open enrollment is, according to a new survey from Policygenius. And 18 percent didn't realize the Affordable Care Act was still the law.

This year, it's more important than ever to be in the know. Here are six steps you can take to navigate open enrollment.

Watch the mail

In a normal year you would have gotten a letter from your current insurer by now informing you of any changes in your existing plan and what premiums you can expect to pay for 2018. Patients often use these letters to determine if they'll keep their current coverage and to help them compare it with any alternatives available.

But many insurers have held off on sending renewal notices because of the uncertainty over premium prices. In fact, many insurers are only just now sending out these notices.

Here's why. Last summer when insurers first began filing their premium rate changes for 2018, the industry and state regulators were worried that President Donald Trump would make good on his threat to cut off government cost-sharing reimbursements. And, in fact, he did eliminate those payments earlier this month.

Under the Affordable Care Act, insurers must provide subsidies to low-income patients to help pay for out-of-pocket health-care costs such as deductibles and co-pays. The federal government then reimburses insurers for those subsidies. Now that the federal government has announced it will no longer make these reimbursements, most insurers have raised premiums to offset the costs of unreimbursed cost-sharing payments. (More on premium hikes soon.)  

Efforts to reinstate cost-sharing reimbursements aren't too promising. The Alexander-Murray Bipartisan Health Care Stabilization Act of 2017 is languishing in Congress. And earlier this month a federal judge in California rejected efforts from 18 states and the District of Columbia to force the Trump administration to continue making the payments. 

Legislative and legal challenges are expected to continue, but probably not in time to affect the 2018 enrollment period.

The good news: As it stands now, if you qualify for cost-sharing subsidies you'll still receive them (even though your insurer won't be reimbursed). But overall premium prices will rise as a result.  

Get off to a fast start 

No matter what news you receive from your current insurer, you want to start researching your options as soon as open enrollment begins. That's because the Trump administration has significantly decreased  the number of days in the open-enrollment period, so you have less time to make your decision. 

In the 39 states in which the federal government runs the exchange, open enrollment runs from Nov. 1 until Dec. 15 for coverage starting January 2018. Some states that run their own exchanges will have longer open-enrollment periods. And some people whose current plan won't be offered next year may qualify for more time to get coverage if they miss the Dec. 15 deadline.

In the shorter time frame you'll also likely have fewer places to turn for help. Government spending on outreach and advertising for the exchanges has been drastically cut, and funding for "navigators," people who are trained to help consumers choose an exchange plan, has also been reduced dramatically. "The absence of navigators makes things harder," said Tom Bulleit, a partner in the health care practice group at Ropes and Gray.  He suggested that people with tough questions see if the legal aid society in their area can help.  

Don't confuse cost-sharing subsidies with premium subsidies

We've discussed how cost-sharing subsidies work. Premium subsidies are different. These are the tax credits under the Affordable Care Act designed to help low- and mid-income consumers afford their monthly health insurance premium. The majority of exchange customers qualify for premium tax credits.

These tax credits aren't going away, and because they're calculated based on income and the cost of a silver level plan, in most cases premium relief increases as premium rates rise. So consumers who qualify for premium tax credits will likely see little change in how much they pay out-of-pocket for their monthly premium bill, even with the big increases insurers have put through.

However, exchange consumers who don't qualify for premium tax credits will carry the heaviest burden for the current premium hikes.

Compare premiums for all metal levels

Exchange insurance programs come in four levels: bronze, silver, gold and platinum. The higher the level, the more comprehensive the coverage, the less out-of-pocket costs and, normally, the higher the premiums.  

But because cost-sharing subsidies are available only in silver plans, they've undergone the highest premium increases to make up for the lack of government funds. "Surcharges on silver plans attributed to the end of the cost-sharing payments range from 7.1 percent to 38 percent," according to a recent analysis from the Kaiser Family Foundation.

"That means we're in a situation where gold plans, with more comprehensive coverage, may actually be cheaper than silver," explained Katherine Hempstead, senior adviser at the Robert Wood Johnson Foundation. This year, it's really worthwhile to compare all metal level plans," she advised.

This works on a case-by-case basis. Some insurers have applied premium increases to all metal level plans to help pay for the lack of cost-sharing reimbursements. So depending on your exchange, you may see increases across the board. According to the Kaiser analysis, premium increases ranged from 0.1 percent to 27.2 percent across all metal level plans due to the end of cost-sharing reimbursements.

Every exchange market will have at least one insurer for 2018 coverage, and many of those are expected to offer various metal level plans. Bottom line: Even if it looks as if you have only one insurer choice, be sure to look at all the plans that one insurer is offering. And keep in mind that premium tax credits can be applied to any level plan.

Beware auto enrollment

This is when your current exchange insurer automatically renews your coverage. But you may not be getting the same coverage. Premium prices, provider networks and out-of-pocket costs may change. For all the reasons we've discussed above, you need to compare the plan you've been automatically renewed into with any alternatives you may have.

Don't go naked

Earlier in the year, there was speculation that the Trump administration would look the other way if the IRS didn't enforce penalties for people who don't get health insurance coverage. This individual mandate is one of the most debated aspects of the ACA. But the IRS announced earlier this month that it will require taxpayers to disclose whether they have purchased health insurance. 

So be warned. If you go without, you will face the penalty. 

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