The Ultimate Guide to Health Insurance Open Enrollment

Open Enrollment Benefits

In order to comply with the Affordable Care Act, all health insurance plans must at a minimum satisfy the ten essential health benefits defined by the legislature. This mandate applies to all plans created after March 2010. Before then, less than two percent of plans provided all ten benefits.

If you believe you enrolled in a health insurance plan prior to 2010, it may have been grandfathered in. Unfortunately, many insurance companies have dropped these plans in order to comply with federal law. If this is the case for you, it is imperative you switch to plans that do provide this coverage on the exchanges.

The ten essential health benefits are:

  1. Preventive and wellness visits: Preventive care visits have no copay under Obamacare. This includes support for breastfeeding, contraception, and domestic violence screening.
  2. Maternity care: Considered preventive care, maternity, and newborn care is provided without cost.
  3. Mental and behavioral health treatment: This includes treatment for alcohol, drug, and other substance abuse.
  4. Services to help people with injuries, disabilities, or chronic conditions: The ACA requires coverage for equipment needed to treat chronic diseases.
  5. Lab tests.
  6. Pediatric Care: Dental and vision care is covered.
  7. Outpatient Care.
  8. Prescription Drugs: Plans must cover at least one drug in every category in the U.S. Pharmacopeia.
  9. Emergency Room Services: Obamacare plans don’t charge extra if you go to a hospital without pre-authorization.
  10. Hospitalization: Not all plans cover hospitalization, as costs can be incredibly hefty. A single day can cost between $2000 and $20,000.

In addition to the essential health benefits, all plans through the health insurance Marketplace cover pre-existing conditions and preventive services.

As a quick note, keep in mind that the above list has been written and edited for clarity to discuss a broad overview of the benefits one can expect when enrolling in an ACA compliant health insurance company.


In addition, not all insurance plans will offer the same degree of coverage. Obamacare allows each state to create a benchmark plan that all others plans will model, to make sure it is not too expensive for businesses to offer.

Before you apply for insurance, it’s critical you speak with trusted professionals who can ensure you fully understand what plan you decide to purchase.

Marketplace Coverage Plans

Consumerism in healthcare is a rising trend that encourages patients to be stewards of their own healthcare, making decisions based on the quality of care and cost. To offer you the most options to meet your financial needs, there are four types of plans.

  1. Bronze: Health plan pays 60% of the medical bill, you pay 40%. Out-of-pocket costs are the highest but have the lowest monthly costs
  2. Silver: Health plan pays 70% of the medical bill, you pay 30%. The most common choice because their costs fall in the middle compared to the other plans.
  3. Gold: Health plan pays 80% of the medical bill, you pay 20%. They have high premiums, meaning that you’ll have less out-of-pocket costs in the form of deductibles, copays, and coinsurance.
  4. Platinum: Health plan pays 90% of medical bill, you pay 10%. Out-of-pocket costs are the lowest but have the highest monthly costs.

Keep in mind that these percentages aren’t always that clear-cut. You might pay more or less for a service. It all depends on what’s detailed in your insurance terms.

Who Can You Claim as a Dependent?

Figuring out who you can claim as a dependent is an important part of the Open Enrollment process. It will affect the type of health insurance coverage you’ll receive and whether or not you qualify for discounts. But claiming dependents is not as clear-cut as writing down the names of every person that lives in your household.

Why is that?

Because the government has a very specific definition of what a household is. I’ll explain.

The government defines a household as:

  1. The person who files the taxes
  2. Their spouse (if they have one)
  3. Any tax dependents

This is your tax family, which can be different from your coverage family—the people who you share a plan with. For example, your coverage family might be your boss and coworkers, while your tax family might be your wife or husband, and children.

Here are a few tips on who you can claim as a dependent

  • You can include your parents only if you’ll claim them as tax dependents. The same is true for siblings and other relatives.
  • Include any child under 21 you take care of and who live with you.
  • You can’t include a legally separated spouse, even if you live together.
  • Don’t include a baby until it is born. You have up to 60 days after the birth to enroll your baby.
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