Open Enrollment: What HIV Providers Need to Know

November 1, 2015

When Is the Enrollment Period for Marketplace Coverage?

The 2016 open enrollment starts Nov. 1, 2015 and ends January 31, 2016. For coverage effective Jan. 1st, patients should enroll by Dec. 15, 2015. Learn more about key dates and how to prepare for enrollment.

Enroll/Re-Enroll: Visit:

Will Patients Be Auto-Enrolled?

In most states with federally facilitated marketplaces, most individuals who do not take action by Dec. 15th will be auto-enrolled in their current or a similar plan. Individuals who are auto-enrolled may change plans until January 31, 2016. Learn more.

It is important for patients to review their health plan options because their current plan's drug coverage, premiums, cost sharing and provider networks have likely changed. Patients receiving assistance from ADAP also should check with the state before enrolling as plans eligible for premium assistance may have changed.

Who is running your marketplace? Visit KFF to see if it is your state or the federal government.

Tips for Patients
  • Re-evaluate options. Plan formularies, cost sharing and provider networks change.
  • Take action by Dec. 15, 2015 to ensure coverage Jan. 1.
  • Check with your state ADAP for premium assistance.

Can Patients Enroll or Change Plans After January 31, 2016?

After Jan. 31st, enrollment or plan changes will only be allowed for a "qualifying life event." Examples of qualifying life events include loss of coverage, moving to a new state or change in family size, e.g., the birth of a baby or death of a spouse. Learn more. Medicaid enrollment is ongoing throughout the year.


Will My Patients Be Required to Enroll in Some Form of Coverage?

Most individuals are now required to have health insurance coverage. Learn more. Most individuals are now required to have health insurance coverage. Learn more.

In 2016, the penalty for not enrolling will be $695 per person ($347.50 per child under 18) or 2.5% of annual income (based on income above the tax filing threshold), whichever is greater. The penalty will be assessed when federal taxes are filed for 2016.

Where Can My Patients Get Help With Enrolling?

Help is available in every state. Assistance is available through Navigators, In-Person Assisters and Certified Application Counselors. Learn more. A worksheet is available to help enrollees with HIV select a health plan.

Health plan prices, drug formularies and provider networks are available from Plans are required to provide links to formularies and provider networks directly from the website. Patients should confirm the information with the plan if possible. New enrollees will need social security numbers, employer and income information and policy numbers for current health coverage (if they have it).

HIV-specific enrollment tools and resources are available from the Affordable Care Enrollment Center. More information on the ACA for people with HIV is available from the Greater than AIDS Health Coverage HIV & You portal.

Is Assistance Available for Premiums and Cost Sharing?

In 2015, a large majority (around 85%) of marketplace enrollees, received premium assistance. Premium assistance through tax credits is available for those with incomes between $11,770/year (100 percent FPL) and $47,080/year (400 percent FPL) for an individual. Enrollees can choose to have the credit paid directly to the plan to lower their monthly premium or receive the credit in a lump sum when they file taxes at the end of the year. Learn more.

Check With ADAP

As of Sept. 2015, 44 ADAPs offered assistance purchasing coverage.

Check with your ADAP.

Kaiser Family Foundation FAQs

What Should Be Considered When Selecting a Plan?

Patients will need to carefully evaluate their options to assess if their medications are covered and if providers and pharmacies are in the plan's network. It is important to consider the plan's total out-of-pocket costs, including the premium, deductible and co-payments or cost-sharing for services, e.g., the co-payments for HIV medications. Information on prior authorization or other restrictions on drug coverage also should be available and considered. A plan with a higher monthly premium is likely cost effective for many patients because of seeing their higher use of health services and prescription drugs.

What About Patients Who Would Have Been Eligible for the Medicaid Expansion?

In non-Medicaid expansion states, individuals who would have qualified for Medicaid coverage if their state had expanded also are exempt from the coverage requirement. These individuals will continue to be eligible for Ryan White services and treatment. It is important for them to still apply for coverage and be denied so that they may enroll during the year if their income changes or in case they are eligible for traditional Medicaid. Learn more.

What Happens if My Patient Does Not Enroll?

Ryan White grantees are required to make every reasonable effort to enroll uninsured patients who are eligible in coverage and document that they have done so. If patients remain uncovered after "vigorous" efforts to enroll them, Ryan White grantees can elect to cover their care and treatment. Programs should have in place a policy for enrolling eligible uninsured patients and document steps as they are taken with each patient. Learn more.

What Can I Do to Ensure My Patients Have the Option to Continue to Receive Services at Our Clinic?

It is important to make sure that providers contract with the large Marketplace and Medicaid managed care plans in their area, and let patients know the health plans they can enroll in to continue to receive HIV care from their current providers. Qualified Health Plans are required to contract with some Essential Community Providers, including Ryan White providers. Providers cannot steer patients to a plan but can provide patients with information, including the plans that they contract with.

The HIV/AIDS Bureau funds the National Technical Assistance Center for Contracting and Reimbursement Expansion to assist Ryan Whitefunded providers with contracting with health plans. Learn more.


Enrollees should report any changes in income during the year. There will be a reconciliation process at the end of each year. If an individual's income increases during the year, changing their eligibility for premium assistance, they will be held responsible for the difference when they file their taxes.


Affordable Care Enrollment (ACE)

Marketplace Plan Renewal Flowchart

Enroll America -- Get Covered 101

Health Insurance Literacy Hub

FamiliesUSA Enrollment Resource Center

Greater than AIDS -- Health Coverage HIV & You

Ryan White & the Affordable Care Act: What You Need to Know -- On Demand Webinars

Ryan White & the Affordable Care Act -- Guidance and More


Kaiser Family Foundation
Updated FAQs Help Consumers Understand the ACA Marketplaces As Third Open Enrollment Begins

National Alliance of State and Territorial AIDS Directors -- ADAP Supports Expanded Access to Care (Sept. 2015)

ADAP/Part B Programs Currently Purchasing Qualified Health Plans (QHPs) for Clients (September 2015)

Related Stories

Higher Rate of Viral Suppression Found in ACA Enrollees Than in Those Supported Only by Ryan White

This article was provided by HIV Medicine Association. Visit HIVMA's website to find out more about their activities, publications and services.

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