Can I change my ACA plan type during the year?

If my needs change, can I switch from a Bronze plan to a Silver or Gold plan mid-year?

Generally, once you’ve enrolled in an ACA Marketplace plan, you cannot switch plans mid-year unless you qualify for a Special Enrollment Period (SEP). The Open Enrollment Period is the designated time when you can freely change or select a new plan, but a Special Enrollment Period allows you to make changes if you experience certain life events during the year. Here’s what you need to know about switching from a Bronze plan to a Silver or Gold plan mid-year:

1. Open Enrollment Period

• The Open Enrollment Period typically runs from November 1 to January 15 each year. During this time, you can:

  • Enroll in a new plan.

  • Switch from one plan tier to another (e.g., from Bronze to Silver or Gold).

• If you want to change plans outside of Open Enrollment, you’ll need to qualify for a Special Enrollment Period (see below).

2. Special Enrollment Period (SEP)

You can switch from a Bronze plan to a Silver or Gold plan mid-year if you qualify for a Special Enrollment Period (SEP). SEPs are triggered by certain qualifying life events that allow you to make changes to your health coverage outside of the annual Open Enrollment Period. Here are some of the qualifying events:

A. Loss of Other Coverage:

• If you lose your current health coverage, such as losing employer-sponsored insurance or COBRA coverage, you can qualify for an SEP and switch to a Silver or Gold plan.

B. Change in Household:

• Events like getting married, having a baby, adopting a child, or losing a family member can trigger an SEP, allowing you to change your health plan.

C. Change in Residence:

• If you move to a new state or a different area where your current health plan is no longer available, you qualify for an SEP and can switch to a new plan, including upgrading from Bronze to Silver or Gold.

D. Change in Income:

• If your income changes, affecting your eligibility for premium tax credits or cost-sharing reductions (CSRs), you may qualify for an SEP. For example, if your income drops and you become eligible for cost-sharing reductions, you may want to switch to a Silver plan, since CSRs are only available for Silver plans.

E. Other Qualifying Events:

• Events such as gaining U.S. citizenship, leaving incarceration, or a change in your dependent status may also trigger an SEP.

How to Use an SEP:

• If you experience any of these qualifying life events, you typically have 60 days before or after the event to enroll in a new plan or switch your existing plan.

• Visit tsunamihealth.com or contact a Tsunami Advisor to report your life event and explore your new plan options during the SEP window.

3. Can I Change Plans If My Health or Financial Needs Change?

If your healthcare needs or financial situation change mid-year but you don’t qualify for an SEP, you’ll generally have to wait until the next Open Enrollment Period to switch from a Bronze plan to a Silver or Gold plan. However, consider the following:

• Premium tax credits and cost-sharing reductions can still adjust if your income changes significantly during the year, even if you can’t switch plans right away.

• Update your income information with the Marketplace as soon as your income changes to ensure you’re receiving the correct level of financial assistance.

4. When You Can’t Switch Mid-Year

Without a qualifying life event that triggers an SEP, you will not be able to switch your plan mid-year. This applies even if:

• Your healthcare needs change (e.g., you start needing more frequent doctor visits or prescriptions).

• You want a plan with lower deductibles or better coverage.

• You missed the Open Enrollment Period and now want to change plans.

5. What to Consider Before Changing Plans

If you qualify for an SEP and are thinking about switching from a Bronze plan to a Silver or Gold plan mid-year, consider the following:

• Monthly Premiums: Silver and Gold plans typically have higher premiums than Bronze plans, but they offer lower out-of-pocket costs when you need care.

• Out-of-Pocket Costs: A Silver or Gold plan may be better if you anticipate needing frequent healthcare services, as they offer lower deductibles, copayments, and coinsurance.

• Cost-Sharing Reductions (CSRs): If your income qualifies, you may receive CSRs that lower your out-of-pocket costs, but this benefit is only available with Silver-level plans.

Key Takeaways:

• You can switch from a Bronze plan to a Silver or Gold plan mid-year only if you qualify for a Special Enrollment Period (SEP) due to a qualifying life event.

• SEPs are triggered by events such as losing other coverage, changes in household, changes in income, or moving to a new area.

• Without a qualifying life event, you must wait until the Open Enrollment Period to change your plan.

For help determining whether you qualify for a Special Enrollment Period or exploring your plan options, schedule an appointment with a Tsunami Advisor here: Schedule an Appointment.