Open Enrollment Frequently Asked Questions

What is Open Enrollment?
This is the time for each New Mexican resident to enroll in coverage for 2017 or review their current coverage and make a change to another plan.

When is Open Enrollment?
Open Enrollment begins November 1, 2016 and ends January 31, 2017.

What would be my effective date of coverage?
If you enroll any time between November 1, 2016 and December 15, 2016 and make your first premium payment by the due date specified by your plan, your new health coverage will begin January 1, 2017.

After that, if you enroll between the 1st and 15th of the month and pay your premium by the due date, your coverage begins the first day of the next month. For example:  If you enroll on January 10, 2017, your coverage will begin February 1, 2017.

If you enroll between the 16th and the last day of the month and pay your premium by the due date, your effective date of coverage will be the first day of the second following month. For example:  If you enroll on January 16, 2017, your coverage will begin March 1, 2017.

If my policy is cancelled by the Carrier as of December 31, 2016, how long do I have to enroll into another coverage?  You have two options.

Option 1: Complete an enrollment application no later than December 15th, for a January 1, 2017 effective date to avoid a break in coverage.
Option 2: If you were enrolled in Presbyterian coverage in 2016, and that plan has ended, you qualify for an extended enrollment period. You may complete an enrollment application through February 28th, for a March 1st effective date. However, if you do not apply for coverage by December 15, 2016, you will be without coverage as of January 1, 2016

I received notice from my carrier that they will no longer be offered as an option on the Marketplace for 2017. I’m in the middle of treatment and concerned about changing my providers during this course of care. What are my options?
Each carrier offers transition of care services, which are usually available for 30 days from your effective date with the new carrier, or a timeframe based on medical necessity. Please check with the new carrier you choose, regarding their Transition of Care guidelines and forms.

I like my Marketplace plan just the way it is, will it stay the same for 2017?
It depends.  Insurers are allowed to make changes to policies each year.  Most likely, the premium for your 2016 policy will change in 2017.  There may be other changes as well, for example, changes in the deductible, coinsurance, or copays for some services.  In some cases, an insurer may stop offering a particular policy and offer you new choices instead.  Shortly before Open Enrollment begins, you should receive a notice from your insurance company stating either the discontinuance of your plan or informing you of any premium changes. If you want to continue the policy, you can renew coverage for another year.  If you prefer to shop for other coverage, you can do that during Open Enrollment.

I enrolled through an insurance broker last year, do I need to use that broker again this year?
You’re not required to use a broker or even the same broker as you did last year. However, a broker does provide value in helping you navigate your options and provide guidance regarding questions you may have about health insurance coverage.

I’m eligible for health benefits at work, but I want to see if I can get a better deal at the Marketplace. Can I do that?

You can always shop for coverage on the Marketplace, assuming you meet other eligibility requirements, but if you have access to job-based coverage, you likely will not qualify for premium tax credits. You may only qualify for premium tax credits if the premium for your employer-sponsored coverage is more than 9.66% of your yearly household adjusted gross income, or if the plan does not meet minimum essential coverage standards.

If I have not filed taxes in a prior year, how will the Marketplace determine my income?
If an applicant did not file taxes in a prior year, income will be verified by the Marketplace through use of electronic wage data. If the information cannot be verified electronically, the applicant may be asked to submit additional documentation within 90 days, such as pay stubs, a work contract or other verification of income.

I intend to shop for new coverage for next year, but didn’t get around to it until January. Meanwhile the Marketplace already renewed my coverage, can I still make a change? If you pick a new plan by January 15, coverage under the new plan will take effect on February 1.  If you pick a new plan between January 16 and January 31, coverage under the new plan will take effect March 1.  In order to avoid a gap in coverage, you will have to pay the premium for your current policy until your new coverage takes effect.

What is the penalty, if I don’t have insurance?
The penalty for not having minimum essential coverage is either a flat amount, or a percentage of household income, whichever is greater. In 2016, the penalty is the greater of:
  • $695 for each adult and $347.50 for each child, up to $2,085 per family, or
  • 2.5% of family income above the federal tax filing threshold.

How do I file an appeal through the Marketplace? You can request an appeal of any Marketplace decision, including decisions about
  • Your eligibility to buy coverage in the Marketplace
  • Your eligibility for, or the amount of, premium tax credits or cost sharing reductions
  • Your eligibility for an exemption from the penalty for not having health insurance
  • Untimely (late) notice from the Marketplace about a decision
To make your appeal, start by reviewing the Marketplace’s decision. You will have received the decision (called a determination notice) online if you initially applied online, or in the mail if you submitted a paper application. So far, in the federal Marketplace, the notice will not provide much detail to explain the reasons for the decision, but it will describe the process you should follow if you want to appeal. To request an appeal in federal Marketplace states, you’ll have to submit the appeal in writing.  You can write a letter or use appeal forms available on https://www.healthcare.gov/downloads/marketplace-appeal-request-form-a.pdf.  Your written appeal should provide your name and contact information and an explanation of what you are appealing and why.
 
You can submit documents to the Marketplace that support your case. You can submit documents along with your initial appeal request or at any time during the appeal process, up until a hearing.
The Marketplace may offer you the option of receiving temporary benefits while your appeal is pending. You can accept the temporary benefits or waive them. If you accept temporary benefits during the appeals process and then lose your appeal, you might have to pay back the benefits you weren’t eligible for.

The Marketplace will review your completed appeal once it is submitted. Then the Marketplace will let you know its decision.  If you still disagree with the decision, you can request a hearing. While you are waiting for the hearing to take place, the Marketplace may contact you to try to resolve the dispute informally.
 

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