Open Enrollment and Special Enrollment Periods

One VERY significant change to the individual health insurance market made by The Affordable Care Act (ACA, Obamacare) is the implementation of open enrollment and special enrollment periods.  Prior to the ACA, an individual could purchase health insurance from an insurance carrier anytime, but the insurance carrier could reject an application, based on a pre-existing condition of the applicant.

Open Enrollment and Special Enrollment Periods

The ACA bans insurance carriers from denying applications based on pre-existing conditions, so without a stricter enrollment period, consumers could simply wait until they were stricken with a severe condition to purchase health insurance.  This is referred to as “adverse selection”, and defined open enrollment periods attempt to limit such negative statistics for insurance carriers.

The first open enrollment period under the ACA expired March 31, 2014.  The next open enrollment period will run from November 2014 to February 2015, for health plans with effective dates in 2015.  So, generally, if you did not purchase insurance by March 31st of 2014, you will have to remain uninsured until 2015, unless you have a qualifying event, in which case you will be eligible to enroll during a Special Enrollment Period (SEP).

SEP’s exist to allow certain people to enroll outside of the regular open enrollment period, if they have an event that leaves them without health insurance coverage.  Qualifying events are:

1)     Loss of Coverage –

  • Insurance through an employer was cancelled
  • Lost job and, with it, health insurance
  • COBRA expired  (NOT if simply stop paying COBRA premiums)
  • Turned 26  and cannot stay on parents’ plan
  • Medi-Cal eligibility changes or denials

2)     Change in household status –  marriage, domestic partnership, divorce, adoption, birth, death of a spouse

3)     Permanent change of residence

4)     Substantial changes in income that will change qualification for premium assistance credit

5)     Gain citizenship

If I have a qualifying event, how long do I have to enroll in a new health plan?

Generally, you have 60 days from the date the qualifying event happens to enroll in a health plan.

Do I need to submit proof of the qualifying event?

Yes.  Be prepared to attach a note from your employer, cancelled health insurance notice, marriage license, divorce decree, birth certificate, etc…. to your application.

How do I avoid gaps in health insurance coverage?

In general, the start date for coverage depends on the date you enroll, so to the extent you can plan ahead, do.  If you enroll by the 15th day of the month, your coverage will start on the first day of the next month.  If you enroll after the 15th day of the month, your coverage will start on the first day of the second month.  Example:  enroll on June 13th and coverage is effective July 1st.  Enroll on June 16th, coverage is effective August 1st.

What if I cannot plan ahead, such as if I lose my job suddenly?

If you lose Medi-Cal coverage, job-based coverage, or other health insurance unexpectedly, your coverage would start on the first day of the next month, regardless of when you enroll.

Under what other circumstances can coverage begin right away?

Marriage, adoption, birth and on a case-by-case basis as determined by Covered CA.

Can an agent help me with the Special Enrollment Period?

Yes.  Use an agent that has been certified by Covered CA to determine whether you qualify for premium tax credits.

 

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