Covered CA Special Enrollment Rules §6504

only apply to get – enroll – sign up for Health Insurance when it’s NOT Open Enrollment

• Get an instant Quote & Enroll!
• IMHO The simple way to review the Special Enrollment Rules – is the plain English  Insurance Company brochures below, rather than reviewing the actual legal code
  • Medicare Advantage MAPD Special Enrollment and turning 65 Rules

Trump Big Beautiful Bill Changes

• For those with Obamacare plans, Covered CA the new legislation will make it harder to enroll and to retain their coverage.
• ACA marketplace Covered CA  policyholders will be required to update their income, immigration status, and other information each year, rather than be allowed to automatically reenroll — something more than 10 million people did this year. They’ll also have less time to enroll; the bill shortens the annual open enrollment period by about a month.
• People applying for coverage outside that period — for instance because they lose a job or other insurance or need to add a newborn or spouse to an existing policy — will have to wait for all their documents to be processed before receiving government subsidies to help pay their monthly premiums. Today, they get up to 90 days of premium help during the application process, which can take weeks.
• Republican lawmakers and some conservative policy think tanks, including the Paragon Health Institute, say the changes are needed to reduce fraudulent enrollments, while opponents say they represent Trump’s best effort to undo Obamacare.
• The legislation also does not call for an extension of more generous premium subsidies put in place during the covid pandemic. If Congress doesn’t act, those enhanced subsidies will expire at year’s end, resulting in premiums rising by an average of 75% next year, according to KFF.    See our subsidy webpage.  
• insurance news net.com/ new-rules 
• 2025 Marketplace Integrity and Affordability Final Rule  

Older Special Enrollment Periods 

News, Links & Resources

• This Open Enrollment Season, Look Out for Health Insurance That Seems Too Good to Be True  
• Why insurers are cutting broker pay for exchange plans
  • Frequently Asked Questions on Agent/Broker Compensation and Guaranteed Availability of Coverage 
• California Senate Bill 260 (CA SB 260) requires  all health plans — to share member contact information with Covered California™ when a member’s health coverage terminates.

Permanent Move 

FAQ’s  “Move – New County, State or Back in USA”

• What does “#intends to reside” mean?
  • For the purposes of § 155.305(a),”intends to reside” means that an applicant has a present intent to reside where he or she is living, and intends to remain in the Exchange service area where he or she is seeking coverage. Individuals visiting an Exchange service area for a transitory purpose, for example, to attend to a business matter, obtain medical care, or for personal pleasure, do not have a present intent to reside, and do not meet the residency requirement for Marketplace coverage for the Marketplace service area they are visiting.
  • Certain individuals who cannot indicate intent, such as children, can establish residency without showing intent to reside. For more information, see Questions 1 and 4 as well as 45 C.F.R. § 155.305(a)(3) and 42 C.F.R. § 435.403.
• Does an individual’s residence change when he or she leaves an Exchange service area temporarily?
  • No. An individual who leaves an Exchange service area temporarily with intent to return to the original Exchange service area continues to be a resident for the purposes of Marketplace coverage during the temporary absence.
• Permanent Move S E P
  • How does someone qualify for the Permanent Move S E P to enroll in a QHP or change their enrollment in a QHP?
    • To qualify for the Permanent Move S E P under 45 C.F.R. § 155.420(d)(7), a QI or his or her dependent must gain access to new QHPs as a result of a permanent move.
    • For the purposes of qualifying for this S E P, a move is considered permanent if a QI (or his or her dependents) moves and meets the Marketplace residency requirement—as described in Questions 1 and 4 with respect to a new location. An individual who moves to a new location temporarily without an intent to reside there or otherwise meeting the Marketplace residency requirement, including for personal pleasure or to obtain medical care, does not qualify for the Permanent Move S E P.
    • Similarly, an individual who moves permanently, but does not gain access to new QHPs as a result of the move, would not qualify for the Permanent Move S E P. For example, this may occur if an individual permanently moves within the same apartment building, neighborhood, town, or county, depending on the QHPs offered in the individual’s service area.  regtap.info/FAQ_Residency Permanent Move_SEP pdf
• So, if you cancel coverage, I don’t see how you would qualify to get coverage when you come back to USA.
  • There are travel policies that you can get.
  • Here’s our page on coverage out of country. Do NOT take our summary as Gospel. Read your Evidence of Coverage!
  • Get quotes here.
  • Don’t forget, if you get hurt, sick, ill, kidney disease, cancer, etc. outside the USA, you can always come back and get follow up treatment here. How much does chronic care treatment cost?
  • Blue Shield Proofs Required
• I’m a US Citizen along with my wife and children. We have been living in China the past two years.
  • 1. How do we get Health Coverage when we come back to the USA? 
  •  2. How do we get a 1095 A or B so we can file our taxes?   
  • 3. What’s this you said on the phone about an exemption?
    • 1. When you will come back, if it’s not Open Enrollment, you would qualify for a Special Enrollment CFR 155.420 (d) (7) as it’s a move to a new region. Get FREE no obligation quotes here.
    • 2. You don’t need a 1095 A, as your exempt from the mandate and not being in the USA – Service Area, you wouldn’t qualify to buy coverage.
    • 3. File form 8965 to show that you are exempt from the mandate. Links and instructions are on this page.
    • Citizens living abroad and certain noncitizens—
      • You were:  A U.S. citizen or a resident alien who was physically present in a foreign country or countries for at least 330 full days during any period of 12 consecutive months;A U.S. citizen who was a bona fide resident of a foreign country or countries for an uninterrupted period that includes an entire tax year; Learn More – 8965 Instructions
• “Federal Qualifying Events, Triggers CFR §155.420
  • my daughter is 23 years old and is a full time student. She has a small part time job but she needs insurance because she needs to go to the doctor.

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  • When one needs Medical Services, is not a reason to be able to get Insurance. One purchases coverage beforehand to cover unexpected losses. This is the whole purpose of limited open enrollment periods, strict special enrollment times, avoidance of adverse selection, etc. Learn More
  • In the time before ACA – Obamacare, there was medical underwriting and pre-existing condition clauses.

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• 1. I ran across your website while trying to educate myself on health insurance. My situation is a bit unique, so let me explain:   2. I live in [redated] with my wife and 2 boys ([redated] years).   3. I ended my COBRA in mid-March and need to pick up alternate insurance.  4. Our Blue Cross coverage was great because I could use it in [redacted] (80% covered, I think).   5. We return to California during Summers, and I am there for about 2 weeks per quarter otherwise.   6. While we have about $[redacted] in assets, we currently have very little income.  7. My wife is starting a company out here and I’m working part time, so our combined income is about $40k.  8. I have 2 recurring medications (high blood pressure and high cholestrol) and I don’t mind paying out of pocket so long as I ride on some negotiated insurance price.   9. Are you able to act as an insurance agent for me or can you recommend a policy?  10 The Blue Shield Silver Plans (how I found you) seem to be about $600-$700 per month for the family, which is fine.

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  • 3 Since you lost COBRA – loss of minimum essential coverage, that gives you a Special Enrollment Period to purchase coverage, even though it’s not open enrollment.
  • 4 A PPO plan should be able to be used anywhere. The problem would be using out of network MD’s. That isn’t always 80%. Check the Specimen Evidence of Coverage, our Quote Engine and the brochures.
  • Also check our International and Foreign Visitor Website for full information, enrollment and pricing.
  • 5 So, you have residency here and a California address we can use. See page 25 of the specimen policy as one must reside in the service area to get coverage.
  • This could get confusing, as it’s not really defined what reside means. Here’s the closest definition I’ve found, from the CA Franchise Tax Board.  also, check your evidence of coverage.
  • You are not out of country long enough to qualify for an exemption from the Health Insurance Mandate.
  • 7 Is that MAGI income? See definition. It’s line 37 plus adding back in Foreign Income, Social Security and Tax Exempt Interest. If it is, then you may qualify for subsidies. Please use our FREE Quote Engine, which will not only show you Blue Shield PPO, but all the other plans as well, both in and out of Covered CA.
  • 8 This is the beauty of our quote engine. It will show the reimbursement levels for your Rx – Drugs. I guess you could do them mail order.
  • 9 Yes, I can be your agent. Please enter your information into our FREE Quote Engine, so that we can review your options and possible subsidy.
  • 10 I’m not sure if the $600/month is with subsidies or not. Please use our quote engine. We also need to verify MAGI income

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• “Open Enrollment & Special Enrollment”
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• We qualify for Medi-Cal based on our family income. We’ll just wait till November all the 2021 information is released to apply and it’s officially Open Enrollment.
  • I see no reason for you to delay enrolling in Medi-Cal.  One never knows when they might get ill or have an accident.  Medi Cal has year around enrollment.

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• It’s my understanding that one can change Medi-Cal providers any time, there is no annual open enrollment for Medi Cal.
  • HMO – Managed Care Providers
  • When you start making too much $$$ to qualify for Medi-Cal they will notify you that you are ineligible. Notification when you make too much $$$ for Medi-Cal
  • Then contact me and I get barely minimum wage to help people with Covered CA insure me kevin.com/how-much-do-health-insurance-agents-earn/
  • Don’t forget, you are mandated to let Medi Cal know of changes within 10 days.   report-a-change/
  • I’m NOT an authorized Medi Cal agent.  Covered CA might try to bully me with their one door policy, but I get no training or compensation to enroll people in Medi-Cal.  I just know how to read and analyze.

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• I’m not working, and am wondering when is the next enrollment period, and if there is a more affordable PPO plan (I’m in a grandfathered Plan Now  that is based upon the income I earn?
  • If your income is zero, there is Medi-Cal
  • Medi Cal enrollment is anytime you become “poor.” I don’t get compensated to help you with Medi-Cal. You can place your questions in the comments area on my Medi-Cal website, on the page most relevant. Your Social Worker gets paid to help you along with whatever Medi Cal HMO that you select.
  • Assets are no longer an issue with Medi-Cal for health insurance and there is no estate recovery. Unless you go into a nursing home.
  • For Covered CA subsidies, you need to have MAGI Income of say at least $18K
  • See income chart or get an instant subsidy calculation and proposal.
  • If you want to do a zoom meeting see our scheduler  in the menu above
  • It’s real easy to change your estimated income in our quote engine. If your income drops to Medi-Cal eligibility, then the subsidy will go away. Just put in the new estimate and click update.
  • See above for the Open Enrollment dates according to AB 1309 – the problem is, myself and one other agent are the only ones that read the law. Covered CA often makes up their own rules. We asked on June 17 and they said they didn’t know, but would send out a bulletin when they did.

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• When is a good time to come by and sign up for open enrollment, for medical insurance?
  • Website visitors can set a time for Face to Face, Skype, Facetime or phone by going to our scheduler

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• Does having a newborn affect my chances of getting individual health coverage during this AEP – Open Enrollment Period?
  • Nope. Under Health Care Reform 45 CFR Section 147.108 and Section 2701 there are no pre-existing clauses. It’s all guaranteed issue. Learn more

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• I opened my blue shield portal to pay my bill and lo and behold my rate more than doubled.  What gives?   You told me that by doing nothing my premium and plan would not change. I can understand a rate hike but this is ridiculous.   Anything we can do at this late date?

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  • Generally, when someone with Covered CA has a huge increase, it’s because their income dropped to Medi Cal level and they no longer qualify for subsidies.
  • insure me kevin.com/why-did-my-california-health-insurance-rates-spike-up/
  • See the Income Chart /income-chart/
  • Use our quote engine to verify income, age, zip code, subsidies, etc quotit.net/
  • Unfortunately, we did have another client recently that really did have say a 50% rate increase. It came as quite a surprise to us to, considering the announcement from Covered CA that the average rate increase would be less than 1%. For those people that did shop, we didn’t see any significant rate increases.
  • Let’s check out your specific situation:
    • We see that you have an HDHP plan allowing you to qualify for a Health Savings Account HSA hsa/
    • Well, you’re making a lot more now than last year, thus much lower subsidies.
  • Here’s quotes and alternatives based on $73k income. Will you income hold out with COVID?
  • What did you actually make in 2020? Subsidies IMHO are all hocus pocus and jiggery pokery, until the day of reckoning when you actually file your taxes. premium-tax-credit-8962/
  • subsidies-upheld/
• My income will probably be the same as last year (50K AGI)  Can we get this fixed?
  • Yes, I’ll go in and change it for you. /report-a-change/
  • Please note also, that IMHO it’s better to just give Covered CA your MAGI income = AGI plus Social Security… rather than fill out every single question they ask/magi/#comment-102936
    • Wow, that went easier, quicker and more straight forward than I thought it would.
    • chcf.org/how-many-your-area-are-covered-affordable-care-act/

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• I want to get an Individual plan that UCLA accepts. I went to their webpage ucla health.org/health-plans and they accept WAY MORE plans than just Blue Shield PPO and Oscar EPO!!! They also told me this over the phone.  What’s the problem? Are you trying to sell me just the plans you make the most commission on?

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  • First off, we have to accept that Covered CA controls the CA marketplace, even if you get a plan directly from an insurance company. Check my website for the citation.
  • Here’s the companies that write Individual Coverage in CA for 2020
  • 1. Anthem Blue Cross of California.  2. Blue Shield of California.  3. Chinese Community Health Plan.  4. Health Net.  5. Kaiser Permanente.   6. L.A. Care Health Plan.   7. Molina Healthcare.  8. Oscar Health Plan of California.  9. Sharp Health Plan.   10. Valley Health Plan.  11. Western Health Advantage.   Source – Covered CA.com
  • Go to this link https://individuals.healthreformquotes.com/companies/ and then scroll down for information on each company. You can get quotes here for 2020 on 11.1.2019 Sure you can get quotes from Covered CA or on each companies affliate link – no extra charge for our services, they pay us. It’s just that if you want us to help you compare, our tools won’t be ready till 11.1.2019.
  • So, sure UCLA lists a lot of plans they accept, but how are you as an Individual going to buy them?
  • Preferred Provider Organizations (PPOs)   Aetna – Left CA!  Anthem Blue Cross Left CA in 2018 but came back for 2020  Blue Shield of California  CIGNA – Left CA   First Health  Health Net of California OK, but not on the list for Individual Plans  Interplan (a HealthSmart product)  MultiPlan  UFCM Health System, Inc. dba California Foundation Medical Care (CFMC)  Prime Health Services  Private Healthcare Systems (PHCS)  TriCare Are you Military?  UnitedHealthcare – Left CA for Individual Plans
  • https://www.uclahealth.org/health-plans   If you have Medicare we can help you on this website.
  • If you have a business with at least one non-spousal employee, we can help you here. Group Employer Quotes
  • It might often depend on the question you ask. You might not be asking the right question. Sure, UCLA accepts a lot of Insurance Companies. The question is, what companies can you buy as an individual that they accept?

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• What does Off Exchange mean?

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  • Exchange is a term for the entire United States. It means Health Care . gov, Marketplace  or Covered CA, where you can get subsidies.  Off Exchange, means that your not in Covered CA, but direct with an Insurance Company. Agent support at no additional charge!  Pretty much, the rates and benefits in or out of Covered CA are exactly the same. Same crappy networks, etc.  Due to a lawsuit to end subsidies for enhanced silver, direct is less $$$ if you want a silver plan and are not getting subsidies.  Direct – some of the companies offer plans not available in Covered CA. BUT, they must meet Actuarial Value for the Metal Levels, have essential benefits, be guaranteed issue and no pre X!  We do not care or want to comment about what anyone said over the phone. It’s just too unreliable. The courts won’t even accept hearsay evidence.  Here’s where we spent an hour with our crystal ball, coming up with reasons why someone over the phone said something…

Technical Law 

Verification of Special Enrollment

Consumers and brokers completing an online application will be notified in the application that Covered California may seek to verify the validity of their self-attested Qualifying Life Event (QLE) in order to be eligible for Special Enrollment.

Covered California will contact a random sample of consumers who enrolled during a Special Enrollment Period (SEP) to request proof of the QLE. If the consumer does not provide acceptable documentation of their QLE within 30 days of the date on the original notice, their coverage can be terminated.

If a consumer is found to have been fraudulently enrolled in a Covered California health insurance plan without a Qualifying Life Event, the broker who assisted the consumer could potentially lose their certification.  Brokers don’t risk losing your certification with Covered California and ensure all consumers who attest to having experienced a QLE are able to provide proof that they qualify for special enrollment. ^{February 10, 2021 Bulletin} *

• CMS awards $18 million contract to verify special enrollments  Modern Health Care 2.2.2018 

FAQ

Change more than one time within the 60 day period?

• Question If I lose Employer Coverage, enroll in Cal COBRA or COBRA, but want to get a private – direct individual plan or Covered CA, can I do that, if I decide within 60 days of losing coverage?

• Answer Here’s Blue Shields’ rule
  • a qualified individual, enrollee, or his or her dependent shall have 60 days from the date of a triggering event to select a QHP. § 6504. Special Enrollment Periods (f)
  • I don’t see anything limiting you to only have ONE choice! It may be difficult dealing with the “Rando’s” that don’t look up the law or rules…
  • Does the new ARPA rule about no premium COBRA help you?
• Question termination of employment….” does that include quitting a job?
• Answer Yes.
  • You can double check the actual CA law on the link above for § 6504. Special Enrollment Periods (f)
  • However, since you voluntarily left employment, you wouldn’t get “Free” COBRA for 6 months under ARPA
    • Thank you for your answers. They were quick and to the point.

FAQ

Change in Household Size?

• Question if there is a change in household size, spouse moving to medicare,
  • does this qualify for special enrollment for the spouse that is staying on covered california to change plans within covered california

• Answer While a spouse moving to Medicare might change the number of people on Covered CA, it does NOT change household size.
  • You still get the lower FPL Federal Poverty level to get higher tax subsidies.
  • Here’s the exact definition of household income & tax payer family
  • Flow chart to calculate household size
    • See above for all QLE Qualifying Life Events
    • See our webpage on Medicare
    • See above about using the Pandemic Emergency to make a change in plans.

Historical