More details on loss of coverage and proofs needed
Plain English Version from Blue Shield

Kaiser Rules 2017 16 pages

Kaiser Proof Form & Requirements

Minimum Essential Coverage - Publication 974 - Page 8
Minimum Essential Coverage – Publication 974 – Page 8

One way to have a triggering event for Special Enrollment where you can buy Insurance when it’s not open enrollment, is to lose §155.420 (d) (1)  minimum essential coverage (§5000 A (f) ) .  That is to lose your current health coverage, like a job loss, COBRA expiring, moving and your old coverage no longer covers the new area, etc., see below for more examples and details.  Unfortunately, non-payment of premiums doesn’t count.

Please start your research into Special Enrollment Periods by reviewing our main page of California Code of Regulations on Qualifying Events

Code of Federal Regulations § 155.420  (d) The Exchange [Covered CA] 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. The date of the loss of coverage is the last day the consumer would have coverage under his or her previous plan or coverage.

 Apparently doesn’t include if one loses private or Covered CA subsidied coverage, if one get’s thrown into Medi-Cal

26 CFR 54.9801-6(a)(3)(i)

Special enrollment periods no longer will be available for:

Consumers who were eligible for or enrolled in health coverage through the federal COBRA program but had not been adequately informed about their coverage options;   (Counihan, CMS blog, 1/19).  Learn More ⇒CA Health Line – Health Affairs.org 1.20.2016

(e) Loss of coverage. Loss of coverage described in paragraph (d)(1) of this section includes those circumstances described in 26 CFR 54.9801-6(a)(3)(i) [loss of employer group coverage] through (iii) and in paragraphs (d)(1)(ii) through (iv) of this section. Loss of coverage does not include voluntary termination of coverage or other loss due to—

(1) Failure to pay premiums on a timely basis, including COBRA premiums prior to expiration of COBRA coverage, or

(2) Situations allowing for a rescission as specified in 45 CFR 147.128.

26 CFR 54.9801-6(a)(3)(i)

(ii) Is enrolled in any non-calendar year group health plan or individual health insurance coverage, even if the qualified individual or his or her dependent has the option to renew such coverage. The date of the loss of coverage is the last day of the plan or policy year;

CMS 5.2.2014 5 page guidence

(iii) Loses pregnancy-related coverage described under section 1902(a)(10)(A)(i)(IV) and (a)(10)(A)(ii)(IX) of the Social Security Act (42 U.S.C. 1396a(a)(10)(A)(i)(IV), (a)(10)(A)(ii)(IX)). The date of the loss of coverage is the last day the consumer would have pregnancy-related coverage; or

(iv) Loses medically needy coverage as described under section 1902(a)(10)(C) of the Social Security Act only once per calendar year. The date of the loss of coverage is the last day the consumer would have medically needy coverage.

1902(a)(10)(C) [42 CFR 435.308 Medicaid to those under 21]

If you lose health plan coverage because you didn’t pay your premiums or contributions or because your plan was rescinded, these do not qualify as triggering events.

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. For purposes of this paragraph, both of the following definitions shall apply:

(i) “Minimum essential coverage” has the same meaning as that term is defined in subsection (f) of Section 5000A of the Internal Revenue Code (26 U.S.C. Sec. 5000A).

(ii) “Loss of minimum essential coverage” includes, but is not limited to, loss of that coverage due to the circumstances described in Section 54.9801-6(a)(3)(i) to (iii), [Group Coverage] inclusive, of Title 26 of the Code of Federal Regulations and the circumstances described in Section 1163 of Title 29 of the United States Code. “Loss of minimum essential coverage” also includes loss of that coverage for a reason that is not due to the fault of the individual.

(iii) “Loss of minimum essential coverage” does not include loss of that coverage due to the individual’s failure to pay premiums on a timely basis or situations allowing for a rescission, subject to clause (ii) and Sections 10119.2 and 10384.17.

 

This short presentation will walk you through a scenario that will help address some questions that may come up when you’re counseling consumers who lose their job-based coverage.

Here are most of the triggering events for loss of coverage:

You lose your employer health plan coverage  ♦ More on loss of Employer Coverage CFR 54.98016   other than COBRA) for the following reasons:

• You lose your job.

• Your work hours are reduced so you no longer qualify for health coverage.

• The person who covers you on his/her employer health plan dies.

• You are a dependent on the employer’s health plan and your marital status changes due to a legal separation or divorce, so your eligibility as a dependent ends.

• You lose eligibility for coverage through your employer because you no longer live or work in the service area, and no other group health coverage is available to you.

• You or your dependent meets or exceeds the maximum lifetime benefits of your health plan because of one specific claim.

• You are part of a group of employees who are no longer offered coverage from your employer.

• A dependent child has a birthday and no longer qualifies as a dependent on his/her parent’s health plan.

• Your employer stops contributing premium payments for your group health coverage.

Your COBRA coverage ends.

• Your retiree coverage is terminated or substantially eliminated when your employer declares bankruptcy (Chapter 11).

• You lose your eligibility for coverage because the person who covered you on the employer health plan becomes entitled to Medicare.

• You lose your minimum essential coverage for a reason that isn’t your fault.

Your individual plan, Medicaid, Medicare, or other governmental coverage (but not special Medicaid programs) ends.

Including rate increases cahba.com/

May 2, 2014 CMS Ruling  3. Special Enrollment Periods for Individuals Whose Individual Market Plans are Renewing Outside of Open Enrollment

45 CFR 147.104(b)(2) provides that a health insurance issuer in the individual market must provide a limited open enrollment period beginning on the date that is 30 calendar days prior to the date the policy year ends in 2014. [Individual Plans in CA don’t have renewal periods] In the Proposed Rule on Exchange and Insurance Market Standards for 2015 and Beyond, HHS proposed amending 45 CFR 155.420(d)(1) to adopt a special enrollment period for the FFM that is aligned with the limited special enrollment period in 45 CFR 147.104(b)(2). HHS is currently reviewing comments submitted for the Proposed Rule on Exchange and Insurance Market Standards for 2015 and Beyond.

In light of 45 CFR 147.104(b)(2), consumers may have reasonably expected to have an option not to renew non-calendar year individual market policies and to receive a special enrollment period in the FFM outside of the open enrollment period. Therefore, at this time, in accordance with 45 CFR 155.420(d)(9), HHS will provide special enrollment periods consistent with 45 CFR 147.104(b)(2).

Affected individual market consumers will be able to report to the FFM that they will not renew their plan up to 60 days before the renewal date, and can get coverage in the FFM effective the first of the month following the renewal date. Consumers will also have 60 days from the renewal date to select QHPs in the FFM. If a QHP is selected after the renewal date, coverage will be prospective based on the date of plan selection. These individuals should indicate “loss of other coverage” on their Marketplace application, if they would like to apply for and enroll in a QHP offered by the Marketplace plan, if otherwise eligible.

Your military coverage ended because you returned from active duty.  (Kaiser Brochure)

 

Loss of health insurance

You may qualify for a Special Enrollment Period if you or anyone in your household lost qualifying health coverage in the past 60 days OR expects to lose coverage in the next 60 days.

Coverage losses that may qualify you for a Special Enrollment Period:

Losing individual health coverage for a plan or policy you bought yourself
You may qualify for a Special Enrollment Period if you lose individual health coverage, including if:

  • Your individual plan or your Marketplace plan is discontinued (no longer exists).
  • You lose eligibility for a student health plan.
  • You lose eligibility for a plan because you no longer live in the plan’s service area.
  • Your individual or group health plan coverage year is ending in the middle of the calendar year and you choose not to renew it.
Important: Losing individual coverage doesn’t allow you to qualify for a Special Enrollment Period if you voluntarily drop coverage, if you lose coverage because you didn’t pay your premiums, or if you lose Marketplace coverage because you didn’t provide required documentation to the Marketplace when we asked for more information.     Learn More===> Health Care.Gov

 

Child & Other Pages in Qualifying Events and Open Enrollment Section

 

5 comments on “Loss of Current Coverage MEC

  1. Hi Steve.

    I know the are the expert on all things Covered CA so I had a couple questions regarding medi-cal.

    First, if someone wants to drop medi-cal, is that considered a loss of coverage and can they enroll in any plan now?

    A person in our office just got married. His wife turned 26 last November. I think she was on her mom’s plan until then and then got on medi-cal.

    To put her on his group plan at the office here would cost nearly $400 per month and he said he cannot afford that.

    Will medi-cal bump her off once they find out she is married?

    Their household income is about $55,000.

    Thanks for your help.

    Take care!

    Kenny G

    • It’s not if they want to drop Medi-Cal the question is has their income increased enough that they’re not longer eligible

      Their required to report changes within 30 days I’ll send you the income chart and then you can see what the limit is for Medi-Cal. One can also use our FREE Online Quote System. Chances are they will which will give her a qualifying event (see links and citations above) and then she could get the covered California plan however you then have to look at the 9.5% affordability because if she’s offered a group plan that might stop subsidies

      • So maybe I was incorrect in saying want to drop medi-cal. Does medi-cal check on their income regularly or if they were eligible in January is it their responsibility to notify them when their income changes.

        Does the 9.5% affordability pertain to dependents as well as employees? The employer pays for the employees only.

        • There’s a mandate somewhere that if your income changes you supposed to voluntarily report it to Medi-Cal

          That’s the crazy thing about healthcare reform and the interpretations it could be that the employee gets the premium for free which makes it the 9 1/2% but the dependent has to pay so that the dependant doesn’t get any subsidies

          • Thanks for your help. It is crazy that the 9.5% test only applies to the employee. If he is making around $50,000, that kicks them out of medi-cal, the 9.5% tests kicks out the subsidy for his new wife and he can’t afford the employers plan. So much for “affordable care act”.

            I guess I will have to put her on a high deductible plan with no subsidy once she comes off medi-cal. (Hopefully that will qualify as a “loss of coverage” event.)

            Editors Note – Kenny G is primarily a life insurance agent

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