Covered CA – What is Special Enrollment 2:23 Minutes

In this Beyond the Basics of Health Reform webinar presented by the Center on Budget and Policy Priorities on March 3, 2016, CBPP discussed the circumstances that trigger a special enrollment period that allow consumers to change or newly enroll in health coverage outside of open enrollment and reviewed the timing of coverage effective dates from different triggering events.

Blue Shield on Special Enrollment
Blue Shield Simple Explanations 1.2016
Special Enrollment Rules - Western Poverty Center
Special Enrollment Rules – Western Poverty Center
HCC Short Term Medical - Missed Open Enrollment?
HCC Short Term Medical – Missed Open Enrollment?
Mr. Mip guaranteed issue coverage - minimum essential coverage
Mr. Mip guaranteed issue coverage – minimum essential coverage
Special Enrollment Periods
AB 1461 Special Enrollment Periods
Federal Poverty Level Chart - Income vs Subsidies vs Enhanced Silver
Federal Poverty Level Chart – Income vs Subsidies vs Enhanced Silver
Metal Level Chart
Metal Level – Enhanced Silver Chart
Market Stabilization PDF
Market Stabilization PDF

The Rule Making Process 11 pages pdf

Did you miss Open Enrollment?
Want to get coverage now rather than wait till November to pick a plan for January?

Review the  Qualifying Event – Triggers  (QLE, SEP) listed below:

Federal

5.6.2016 Fact Sheet on Updates

Donald’s  Rule CMS -9929 – P  71 Pages will limit and implement much more vetting. Learn More

Commentary & Explanation  Insure Me Kevin.com

CA Rules

Simplified Blue Shield Summary Chart  in pdf

Covered CA Audit – Enrollment Verification Toolkit Rev. 7.2016

Please note that these pages includes both in and out of Covered CA and both Individual and Employer Plans (Employer Info on Late Enrollment)

Be sure to check the application and/or the footnotes & CFR’s very carefully or just email all your documents to us for review.

Get a FREE Instant Quote & Subsidy Calculation

If you don’t find a trigger  you are pretty much SOL.

Temporary Plan – NO Trigger Required
with free Quotes & ONLINE Enrollment

REASONS – TRIGGERS

CFR §155.420 Special enrollment periods Copied 2.16.2016  See also CA Insurance Code §10965.3 (d) (1) Effective Date

(d) § 155.420  The Exchange must allow a qualified individual or enrollee, and, when specified below, his or her dependent, to enroll in or change from one QHP to another if one of the following triggering events occur:

(1) The qualified individual or his or her dependent either:

(i) Loses minimum essential coverage.

(2)

(i) The qualified individual gains a dependent or becomes a dependent through marriage, birth, adoption, placement for adoption, or placement in foster care, or through a child support order or other court order.

Court order [definition] – mandate to be covered as a dependent (Note – When a divorce is filed, there is a prohibition from deleting spouse and children! FL 110  Legal Treatise Attorney Website on Divorce Automatic Orders)

(ii) Effective January 1, 2017 or earlier at the option of the Exchange, the enrollee loses a dependent or is no longer considered a dependent through divorce or legal separation as defined by State law in the State in which the divorce or legal separation occurs, or if the enrollee, or his or her dependent, dies.

(3) The qualified individual, or his or her dependent, which was not previously a citizen, national, or lawfully present individual gains such status;

No more special enrollment for

Documented immigrants who experienced “system errors” during the federal government’s determination of their advance tax credit payments; and

Documented immigrants with incomes below 100% of the federal poverty level who faced “processing delays” (Counihan, CMS blog, 1/19).  Learn More ⇒CA Health Line – Health Affairs.org 1.20.2016

(4) The qualified individual’s or his or her dependent’s, enrollment or non-enrollment in a QHP is unintentional, inadvertent, or erroneous and is the result of the error, misrepresentation, misconduct, or inaction

(5) The enrollee or, his or her dependent adequately demonstrates to the Exchange that the QHP in which he or she is enrolled substantially violated a material provision of its contract in relation to the enrollee;

(6) Newly eligible or ineligible for advance payments of the premium tax credit, or change in eligibility for cost-sharing reductions. [enhanced-silver]

(7) The qualified individual or enrollee, or his or her dependent, gains access to new QHPs as a result of a permanent move;

(8) The qualified individual who is an Indian, as defined by section 4 of the Indian Health Care Improvement Act, may enroll in a QHP or change from one QHP to another one time per month;

(9) The qualified individual or enrollee, or his or her dependent, demonstrates to the Exchange, in accordance with guidelines issued by HHS, that the individual meets other exceptional circumstances as the Exchange may provide.

 

In recent days Anthem, Aetna and Cigna, all among the top five health insurers, told brokers they will stop paying them sales commissions to sign up most customers who qualify for new coverage outside the normal enrollment period, according to the companies and broker documents.  Learn More – CA HealthLine 1.4.2016     Covered CA to require Insurer’s pay commissions  CA Health Line 2.18.2016

(a) General requirements.

(1) The Exchange must provide special enrollment periods consistent with this section, during which qualified individuals may enroll in QHPs [Qualified Health Plan] and enrollees may change QHPs.

(2) For the purpose of this section, “dependent”, has the same meaning as it does in 26 CFR 54.9801-2, referring to any individual who is or who may become eligible for coverage under the terms of a QHP because of a relationship to a qualified individual or enrollee.

(b) Effective dates

(c) Availability and length of special enrollment periods

(1) General rule. Unless specifically stated otherwise herein, a qualified individual or enrollee has 60 days from the date of a triggering event to select a QHP.

(2) Advanced availability. A qualified individual or his or her dependent who is described in paragraph (d)(1) or (d)(6)(iii) or, beginning on January 1, 2017 or earlier at the option of the Exchange, paragraph (d)(7) of this section, has 60 days before and after the triggering event to select a QHP. Prior to January 1, 2017, a qualified individual or his or her dependent who is described in paragraph (d)(7) of this section may select a QHP in accordance with paragraph (c)(1) of this section.

(3) Special rule. In the case of a qualified individual or enrollee who is eligible for a special enrollment period as described in paragraphs (d)(4), (5), or (9) of this section, the Exchange may define the length of the special enrollment period as appropriate based on the circumstances of the special enrollment period, but in no event may the length of the special enrollment period exceed 60 days.

[77 FR 18444, Mar. 27, 2012, as amended at 78 FR 42321, July 15, 2013; 78 FR 65095, Oct. 30, 2013; 79 FR 30348, May 27, 2014; 79 FR 59138, Oct. 1, 2014; 80 FR 10866, Feb. 27, 2015; 80 FR 38653, July 7, 2015]

More

Release from incarceration

Returning from active duty of the reserve forces of the United States military or the California National Guard

Just Informed of Tax Penalty Risk and didn’t know about it before

CA Insurance Code §10965.3 (d) (1)

(d)

(1) Subject to paragraph (2), commencing January 1, 2014, a health insurer shall allow an individual to enroll in or change individual health benefit plans as a result of the following triggering events:

(A) He or she or his or her dependent loses minimum essential coverage.

(B) He or she gains a dependent or becomes a dependent.

(C) He or she is mandated to be covered as a dependent pursuant to a valid state or federal court order.

(D) He or she has been released from incarceration.

(E) His or her health coverage issuer substantially violated a material provision of the health coverage contract.

(F) He or she gains access to new health benefit plans as a result of a permanent move.

(G) He or she was receiving services from a contracting provider under another health benefit plan, as defined in Section 10965 of this code or Section 1399.845 of the Health and Safety Code, for one of the conditions described in subdivision (a) of Section 10133.56 of this code and that provider is no longer participating in the health benefit plan.

(H) He or she demonstrates to the Exchange, with respect to health benefit plans offered through the Exchange, or to the department, with respect to health benefit plans offered outside the Exchange, that he or she did not enroll in a health benefit plan during the immediately preceding enrollment period available to the individual because he or she was misinformed that he or she was covered under minimum essential coverage.

(I) He or she is a member of the reserve forces of the United States military returning from active duty or a member of the California National Guard returning from active duty service under Title 32 of the United States Code.

(J) With respect to individual health benefit plans offered through the Exchange, in addition to the triggering events listed in this paragraph, any other events listed in Section 155.420(d) of Title 45 of the Code of Federal Regulations.

(2) With respect to individual health benefit plans offered outside the Exchange, an individual shall have 60 days from the date of a triggering event identified in paragraph (1) to apply for coverage from a health care service plan subject to this section. With respect to individual health benefit plans offered through the Exchange, an individual shall have 60 days from the date of a triggering event identified in paragraph (1) to select a plan offered through the Exchange, unless a longer period is provided in Part 155 (commencing with Section 155.10) of Subchapter B of Subtitle A of Title 45 of the Code of Federal Regulations.

CA Code of Regulations 6504 Special Enrollment Periods

Citations – More details

Excerpt from CIGNA 2014 Enrollment Application

Oscar SEP Guidelines * More Detail

CA Agent Training Page 9 

Specimen EOC Page 28 

CFR  § 54.9801-6  

AB 1461  

Health & Safety Code 1399.849    

Health Net Group Manual   

Assurant Life 

Blue Shield Guidelines 

Federal Guidance 3.24.2014 

(Employer Info on Late Enrollment

Covered CA Special Enrollment rule

Kaiser Individual 2015   Form  

Anthem Blue Cross Summary Grid 9.2015? of documentation required  

HN 7.29.2014 Bulletin

We’ve strengthened our rules and clarified our processes for SEPs, so that the people who need to can still easily get coverage, while making it hard for anyone thinking about taking advantage. We also eliminated 7 SEPs, including the SEP for individuals who paid the tax penalty for not having health insurance, contributing to an almost 30 percent year-over-year drop in the number of SEP enrollments during the three months after Open Enrollment. CMS Fact Sheet 6.8.2016

 

Child Pages

Resources & Links

Covered CA Job aid for 2.16.2015 going forward, webpage for Qualifying EventsTwo page flyer

Covered CA – 2015 Special Enrollment Qualifying Life Events – List

4.24.2015 Special Enrollment – How to complete ONLINE application

Insure Me Kevin.com – 2015 Penalties?

Please note too that Blue Cross and it appears all companies Emails dated 1.21.2015 2:07 PM will make coverage effective 1st of the month following the application rather then the crazy 15th and miss a month deadline.

Enrollment Applications –  Individual  –   Small Group

Agent Training – Covered CA

 Agent Website Chatter   More

Navigator Resource Guide

Los Angeles Times   Documentation not required in 2014

Kaiser Foundation FAQ’s

 

AB 1461  Small EmployER Health – Non Grandfathered Requirements  Triggering Events AB 1461

10753.05 (3) A carrier shall provide enrollment periods consistent with PPACA and set forth in Section 155.725 of Title 45 of the Code of Federal Regulations.

A carrier shall provide special enrollment periods consistent with the special enrollment periods required in the individual non grandfathered market in the state, as set forth in Section 10965.3, [AB 1461]except for the triggering events identified in paragraphs (d)(3) and (d)(6) of Section 155.420 of Title 45 of the Code of Federal Regulations with respect to health benefit plans offered through the Exchange.

 

Qualifying events are only observed outside of open enrollment.

During open enrollment everyone is on the same effective date schedule regardless of qualifying event (except newborns). If application is received the 15th or before, effective date is first of the month following. If received after the 15th, effective date is first of the second month following.  From BC Email dated 3.7.2014

 

Agent ONLY

Blue Shield – More Info

Wording from HN ONLINE application

Please check the box next to any Qualifying Event(s) that happened within the last 60 days:

  1. The qualified individual, or his or her dependent, loses minimum essential coverage, which could be due to one of the following reasons (not including voluntary termination of your previous coverage or termination due to failure to pay premiums):
    1. The death of the covered employee.
    2. The termination or reduction of hours, of the covered employee’s employment.
    3. The divorce or legal separation of the covered employee from the employee’s spouse.
    4. The covered employee becoming entitled to benefits under Medicare.
    5. A dependent child ceasing to be a dependent child under the generally applicable requirements of the plan.
    6. A proceeding in a case under title 11 bankruptcy, commencing on or after July 1, 1986, with respect to the employer from whose employment the covered employee retired at any time. In this case, a loss of coverage includes a substantial elimination of coverage with respect to a qualified beneficiary (spouse/domestic partner, dependent child or surviving spouse /domestic partner) within one year before or after the date of commencement of the proceeding.
    7. Loss of minimum essential coverage for any reason other than failure to pay premiums or situations allowing for a rescission for fraud or intentional misrepresentation of material fact.
    8. Termination of employer contributions.
    9. Exhaustion of COBRA continuation coverage.
  2. The qualified individual gains a dependent or becomes a dependent through marriage, domestic partnership, birth, adoption, placement for adoption, or the assumption of a parent-child relationship.
  3. The qualified individual’s, or his or her dependent’s, enrollment or non-enrollment in a health plan is unintentional, inadvertent, or erroneous and is the result of the error, misrepresentation, or inaction of an officer, employee, or agent of the Exchange or HHS, or its instrumentalities as evaluated and determined by the Exchange.
  4. The health plan in which the enrollee, or his or her dependent, is enrolled substantially violated a material provision of its contract.
  5. The qualified individual or enrollee, or his or her dependent, gains access to a new health plan as a result of a permanent move.
  6. With respect to individuals enrolled in non-calendar year individual health insurance policies, a limited open enrollment period beginning on the date that is 30 calendar days prior to the date the policy year ends in 2014.
  7. He or she is mandated to be covered as a dependent pursuant to a valid state or federal court order.
  8. He or she has been released from incarceration.
  9. He or she was receiving services under another health benefit plan, from a contracting provider who is no longer participating in that health plan, for any of the following conditions: (a) an acute condition (a medical condition that involves a sudden onset of symptoms due to an illness, injury, or other medical problem that requires prompt medical attention and that has a limited duration); (b) a serious chronic condition (a medical condition due to a disease, illness, or other medical problem or medical disorder that is serious in nature and that persists without full cure or worsens over an extended period of time or requires ongoing treatment to maintain remission or prevent deterioration); (c) a terminal illness (an incurable or irreversible condition that has a high probability of causing death within one year or less); (d) a pregnancy; (e)care of a newborn between birth and 36 months; or (f) a surgery or other procedure that has been recommended and documented by the provider to occur within 180 days of the contract’s termination date, or within 180 days of the effective date of coverage for a newly covered insure, and that provider is no longer participating in the health plan.
  10. He or she demonstrates to the Exchange, with respect to health benefit plans offered through the Exchange, or to the California Department of Insurance, with respect to health plans offered outside the Exchange, that he or she did not enroll in a health benefit plan during the immediate preceding enrollment period available to the individual because he or she was misinformed that he or she was covered under minimum essential coverage.
  11. He or she is a member of the reserve forces of the United States military returning from active duty or a member of the California National Guard returning from active duty service under Title 32 of the United States Code.
  12. Newly eligible or ineligible for advance payments of the premium tax credit, or change in eligibility for cost-sharing reductions.
  13. He or she loses medically needy coverage under Medicaid (not including voluntary termination of your previous coverage or termination due to failure to pay premium).
  14. He or she loses pregnancy-related coverage under Medicaid (not including voluntary termination of your previous coverage or termination due to failure to pay premium).

     

xx

2 comments on “Qualifying Events, Triggers, Special Enrollment – When it’s not Open Enrollment

  1. Hi Steve,

    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.

    Randy

    • 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.

      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

Leave a Reply

Your email address will not be published.