Special Enrollment Rules §6504

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

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

Wildfire victims, lost job or income during pandemic & recession

Qualifying member clients will be eligible for this new SEP Sept. 1 through Dec. 31, 2020, both on- and off-exchange.

Beginning September 1, 2020, the Qualifying Life Event (QLE) dropdown menu will include “Loss of job or loss of income” to run through December 31, 2020.

Coverage effective dates under the “Loss of job or loss of income” QLE:

  • For new consumers, the coverage effective (start) date will be the first of the month following plan selection or the event date, whichever is later.
  • For existing consumers, the effective date of coverage for a reported change will generally follow the 15th day-of-the-month rule (e.g., a “Loss of job or loss of income” change reported September 24 would have updated case eligibility effective November 1).  Covered CA bulletin 8.25.2020 *

Which event to pick in Covered CA application

 

Blue Shield  
Plain English, Effective Dates & Proof Required for Special Enrollment

Blue Shield Logo - get speical enrollment rules

 

Guaranteed Issue - No Pre X Clause
Quote & Subsidy Calculation 
Find out your premium with Covered CA
or Direct without Subsidies

Instant complementary quotes & subsidy calculation

Missed Open Enrollment?
See our Special Enrollment page

No charge for our complementary services 

Detailed Video Instructions on using our Quote Engine

detailed instructions to use quote engine

How to use our FREE Quote Engine, Subsidy Calculator  and get the MOST from the experience.

When you get a FREE quote, you can also see the benefits, view actual brochures, MD and Hospital Lists all ONE easy process with no obligation & it can be anonymous.   Enter your zip code, date of birth, family - household taxation relationships (MAGI - Definition),    Estimated MAGI - Modified Adjusted Gross Income for the upcoming - current year.  Last years tax return only gives an idea so that Covered CA can approve your advance tax credit to help pay premiums.

If you qualify for tax credits - subsidies and want them in advance (Pros-Cons) of filing your taxes click on "Health On Exchange" - Covered CAillustrated below.

This website and are individual consultation are provided to you FREE of Charge!  We are paid by Covered CA and/or the Insurance Companies to help you.  When you fill out the Covered CA ONLINE Application, just appoint us as your agent under Find Help in the Upper Right Hand Corner so that we get paid for helping you.  Click here for screen shots for more detail of how to do it.  If you prefer, you can pay us a consultation fee in lieu of appointing us as your agent, for educational services only.

You can then see all the quotes on the exchange, showing the Cost Share Reduction - Enhanced Silver  if available, subsidy - tax credit amount and your net premium.    If you click "Off Exchange" you will see more plans and companies which  may have larger provider lists.   Scroll down for more screen shots.

Then click on "View Plan Details" - "View Doctor's & Providers" - to compare and get more information.  Please note that the quote engine does not show enhanced silver, but shows silver at 70%.  Check our chart for the better silver coverage.

Learn more about the right to change plans when Silver Level Enhanced Changes

To apply, click on apply now or use the links in the right hand column, ON THIS PAGE, but it will have you redo the quote for that specific company.   The price is the SAME, no matter if you use us, go direct to Covered CA or the Insurance Company, as mandated by law!  If applying through Covered CA, be sure to sign the form to appoint us as your agent.  It's not all the easy to figure out how to do it on their website.

If you have any questions email [email protected] or call us 310.519.1335

Health Net Rules, from their Paper Application 

Special Enrollment Rules – Western Poverty Center

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10 CCR CA Code of Regulations
§6504 Special Enrollment Periods

(a) A qualified individual

[one who has been determined eligible to enroll through the Exchange in a QHP in the individual market.    Definitions  155.20]

may enroll in a QHP Qualified Health Plan, or an enrollee

[ a qualified individual or qualified employee enrolled in a QHP.

Enrollee also means the dependent of a qualified employee enrolled in a QHP through the SHOP, and any other person who is enrolled in a QHP through the SHOP, consistent with applicable law and the terms of the group health plan.

Provided that at least one employee enrolls in a QHP through the SHOP, enrollee also means a business owner enrolled in a QHP through the SHOP, or the dependent of a business owner enrolled in a QHP through the SHOP.]  

may change from one QHP to another, during special enrollment periods only if one of the following triggering events occurs:

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

Covered CA simplification per email dated 1.29.2020 

If one member of the household has a QLE, [Qualifying Life Event], the rest can use that QLE to also apply. However, they all would have to apply at the same time since a QLE can only used once. 

I asked as I was concerned about the rule that if you qualify because you moved, you had to have had coverage before.

So, it’s any member of the family, not each!

(A) Loses MEC, Minimum Essential Coverage as specified in subdivision (b) of this section. The date of the loss of MEC shall be:

1. Except as provided in subdivision (a)(1)(A)2 of this section, the last day the qualified individual or his or her dependent would have coverage under his or her previous plan or coverage;

2. If loss of MEC occurs due to a QHP decertification, the date of the notice of decertification as described in 45 CFR Section 155.1080(e)(2);

(B) Is enrolled in any non-calendar year group health plan or individual health insurance coverage, including both grandfathered and non-grandfathered health plans that expired or will expire, even if the qualified individual or his or her dependent has the option to renew such coverage. The date of the loss of coverage shall be the last day of the plan or policy year;

(C) Loses Medi-Cal coverage for pregnancy-related services, as described under Section 1902(a)(10)(A)(i)(IV) and (a)(10)(A)(ii)(IX) of the Social Security Act (42 USC 1396a(a)(10)(A)(i)(IV), (a)(10)(A)(ii)(IX)) and Section 14005.18 of the Welfare and Institutions Code. The date of the loss of coverage shall be the last day the consumer would have pregnancy-related coverage; or

(D) Loses Medi-Cal coverage for medically needy, as described under Section 1902(a)(10)(C) of the Social Security Act and Section 14005.21 of the Welfare and Institutions Code, only once per calendar year. The date of the loss of coverage shall be the last day the consumer would have medically needy coverage.

(2) A qualified individual gains a dependent or becomes a dependent through marriage or entry into domestic partnership, birth, adoption, placement for adoption, or placement in foster care, or through a child support order or other court order.

(3) An enrollee loses a dependent or is no longer considered a dependent through divorce, legal separation, or dissolution of domestic partnership as defined by State law in the State in which the divorce, legal separation, or dissolution of domestic partnership occurs, or if the enrollee, or his or her dependent, dies.

(4) A qualified individual, or his or her dependent, becomes newly eligible for enrollment in a QHP through the Exchange because he or she newly meets the requirements specified in Section 6472(c) or (d).

(c) An applicant shall be a citizen or national of the United States, or a non-citizen who is lawfully present in the United States, and is reasonably expected to be a citizen, national, or a non-citizen who is lawfully present for the entire period for which enrollment is sought.

(d) An applicant shall not be incarcerated, other than incarceration pending the disposition (judgment) of charges.

(5) A 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 of an officer, employee, or agent of the Exchange or HHS, its instrumentalities, a QHP issuer, or a non-Exchange entity providing enrollment assistance or conducting enrollment activities. For purposes of this provision, misconduct, as determined by the Exchange, includes the failure to comply with applicable standards under this title, or other applicable Federal or State laws.

(6) An enrollee, or his or her dependent, adequately demonstrates to the Exchange, as determined by the Exchange on a case-by-case basis, that the QHP in which he or she is enrolled substantially violated a material provision of its contract in relation to the enrollee.

(7) An enrollee Definition, or his or her dependent enrolled in the same QHP – Qualified Health Plan, is determined newly eligible or ineligible for APTC (Subsidies) or has a change in eligibility for CSR. [Cost Sharing Reductions – Enhanced Silver]   RIGHT to change Silver Plans!

***View our webpage on change in eligibility due to income change

A change in income is not a Qualifying life event. If you select “other qualifying life event,” it puts a hold on the account.    In the future, for income changes you need to select “none of the above.”  Email dated 03/26/2018 11:57 AM from Covered CA

(8) A qualified individual, or his or her dependent, who is enrolled in an eligible employer-sponsored plan is determined newly eligible for APTC because such individual is ineligible for qualifying coverage in an eligible-employer sponsored plan in accordance with 26 CFR 1.36B-2(c)(3), including as a result of his or her employer discontinuing or changing available coverage within the next 60 days, provided that such individual is allowed to terminate existing coverage.

(9) A qualified individual or enrollee, or his or her dependent, gains access to new QHPs [Insurance Companies] as a result of a permanent move.

(10) A qualified individual who:

(A) Gains or maintains status as an Indian, as defined in Section 6410 of Article 2 of this chapter, may enroll in a QHP or change from one QHP to another one time per month; or

(B) Is or becomes a dependent of an Indian as defined in Section 6410 of Article 2 of this chapter, and is enrolled or is enrolling in a QHP through the Exchange on the same application as the Indian, may change from one QHP to another one time per month, at the same time as the Indian.

(11) A qualified individual or enrollee, or his or her dependent, demonstrates to the Exchange, in accordance with guidelines issued by HHS and as determined by the Exchange on a case-by-case basis, that the individual meets other exceptional circumstances. Such circumstances include, but are not limited to, the following:

(A) If an individual receives a certificate of exemption for hardship based on the eligibility standards described in 45 CFR Section 155.605(g)

(1) for a month or months during the coverage year, and based on the circumstances of the hardship attested to, he or she is no longer eligible for a hardship exemption within a coverage year but outside of an open enrollment period described in Section 6502, the individual and his or her dependents shall be eligible for a special enrollment period if otherwise eligible for enrollment in a QHP.

(B) If an individual with a certificate of exemption reports a change regarding the eligibility standards for an exemption, as required under 45 CFR Section 155.620(b), and the change resulting from a redetermination is implemented, the certificate provided for the month in which the redetermination occurs, and for prior months, remains effective. If the individual is no longer eligible for an exemption, the individual and his or her dependents shall be eligible for a special enrollment period if otherwise eligible for enrollment in a QHP.

(C) If a child who has been determined ineligible for Medi-Cal and CHIP, and for whom a party other than the party who expects to claim him or her as a tax dependent is required by court order to provide health insurance coverage for the child, the child shall be eligible for a special enrollment period if otherwise eligible for enrollment in a QHP.

(D) If an enrollee provides satisfactory documentary evidence to verify his or her eligibility for an IAP (Insurance Affordability Program) or enrollment in a QHP through the Exchange within 30 days following his or her termination of Exchange enrollment due to a failure to verify such status within the 95-day period specified in Section 6492(a)(2)(B), the enrollee shall be eligible for a special enrollment period if otherwise eligible for enrollment in a QHP.

(12) A qualified individual or enrollee is a victim of domestic abuse and spousal abandonment, as specified in 26 CFR Section 1.36B-2T(b)(2)(ii) through (v), including a dependent or unmarried victim within a household, is enrolled in MEC, and seeks to enroll in coverage separate from the perpetrator of the abuse or abandonment. A dependent of a victim of domestic abuse or spousal abandonment who is on the same application as the victim may enroll in coverage at the same time as the victim.

(13) A qualified individual, or his or her dependent:

(A) Applies for coverage on the Exchange during the annual open enrollment period or due to a qualifying life event, is assessed by the Exchange as potentially eligible for Medi-Cal or CHIP, and is determined ineligible for Medi-Cal or CHIP by the State Medi-Cal or CHIP agency either after open enrollment period has ended or more than 60 days after the qualifying life event: or

(B) Applies for coverage at the State Medi-Cal or CHIP agency during the annual open enrollment period, and is determined ineligible for Medi-Cal or CHIP after open enrollment period has ended.

(14) The qualified individual or enrollee, or his or her dependent, adequately demonstrates to the Exchange, as determined by the Exchange on a case-by-case basis, that a material error related to plan benefits, service area, or premium influenced the qualified individual’s or enrollee’s decision to purchase a QHP through the Exchange.

(15) Any other triggering events listed in the Health and Safety Code Section 1399.849(d)(1) and the Insurance Code Section 10965.3(d)(1).

(e) The Exchange shall accept the qualified individual’s or the enrollee’s attestation provided in accordance with subdivision (d) of this section, subject to the following statistically valid random sampling verification process:

(1) The Exchange may select a statistically valid random sample of the qualified individuals or the enrollees who, in accordance with subdivision (d) of this section, have attested that they met at least one of the triggering events specified in subdivision (a) of this section and request, in writing, that they provide documentation as proof of the triggering event to which they attested or for which they qualify. (2) The qualified individual or the enrollee shall provide the requested document(s) within 30 days from the date of the Exchange’s written request, as specified in subdivision (e)(1) of this section, to the Exchange for verification. The Exchange may extend this period if the Exchange determines on a case-by-case basis that the qualified individual or the enrollee has demonstrated that he or she has made a good-faith effort but was unable to obtain the requested documentation during the 30-day time period. (3) Except as specified in subdivision (e)(4) of this section, if the qualified individual or the enrollee fails to submit the requested document(s) by the end of the time period specified in subdivision (e)(2) of this section or the Exchange is unable to verify the provided document(s), the Exchange shall:

(A) Determine the qualified individual or the enrollee ineligible for any special enrollment period; (B) Notify the qualified individual or the enrollee regarding the determination and his or her appeals rights, in accordance with the requirements specified in Section 6476(h); and (C) Implement such eligibility determination in accordance with the dates specified in Section 6496(j) and (k), as applicable.

(4) The Exchange shall provide an exception, on a case-by-case basis, to accept a qualified individual’s or an enrollee’s attestation as to his or her triggering event which cannot otherwise be verified and his or her explanation of circumstances as to why he or she does not have documentation if:

(A) The qualified individual or the enrollee does not have the requested documentation with which to prove a triggering event through the process described in subdivision (e)(1) through (3) of this section because such documentation does not exist or is not reasonably available; (B) The Exchange is unable to otherwise verify the triggering event for the qualified individual or the enrollee; and (C) The qualified individual or the enrollee provides the Exchange with a signed written statement of his or her attestation under penalty of perjury as to the triggering event and the explanation of circumstances as to why he or she does not have the documentation.

(5) The sampling described in this subdivision shall not be based on the qualified individual’s or the enrollee’s claims costs, diagnosis code, or demographic information. For purposes of this subdivision (e)(5), demographic information does not include geographic factors.

(f) Except as provided in subdivision (f)(1) and (2) of this section, a qualified individual or an enrollee shall have 60 days from the date of a triggering event to select a QHP.

(1) A qualified individual or his or her dependent who loses coverage, as described in subdivision (a)(1) of this section shall have 60 days before and after the date of the loss of coverage to select a QHP.

(2) A qualified individual who is enrolled in an eligible employer-sponsored plan and will lose eligibility for qualifying coverage in an eligible employer-sponsored plan within the next 60 days, as described in subdivision (a)(8) of this section, shall have 60 days before and after the loss of eligibility for qualifying coverage in an eligible employer-sponsored plan to select a QHP.

(i) A qualified individual’s coverage shall be effectuated in accordance with the coverage effective dates specified in subdivisions (g) and (h) of this section if:

(1) The individual makes his or her initial premium payment, reduced by the APTC amount he or she is determined eligible for by the Exchange, by the premium payment due date, as defined in Section 6410 of Article 2 of this chapter. In cases of retroactive enrollment dates, the initial premium shall consist of the premium due for all months of retroactive coverage through the first month of coverage following the plan selection date. If only the premium for one month of coverage is paid, only prospective coverage shall be effectuated, in accordance with the regular coverage effective dates specified in subdivision (g) of this section; and (2) The applicable QHP issuer receives such payment on or before such due date.

(j) Notwithstanding the standards of this section, APTC (subsidies) and CSR (Enhanced Silver) shall adhere to the effective dates specified in subdivisions (j) through (l) of Section 6496.

(j) Except as specified in subdivisions (k) and (l) of this section, the Exchange shall implement changes:

(1) Resulting from an appeal decision, on the date specified in the appeal decision; or (2) Affecting enrollment or premiums only, on the first day of the month following the date on which the Exchange is notified of the change.

(k) Except as specified in subdivision (l) of this section, the Exchange shall implement changes for which the date of the notice of eligibility redetermination described in subdivision (h)(2) of this section or the date on which the Exchange is notified in accordance with subdivision (j)(2) of this section is after the 15th of the month, on the first day of the second month following the month of the notice described in subdivision (h)(2) of this section or the month specified in subdivision (j)(2) of this section.

(l) The Exchange shall implement a change associated with the events described in Section 6504(h)(1), (2), (3), (4), (5), and (6) on the coverage effective dates described in Section 6504(h)(1), (2), (3), (4), (5), and (6) respectively.

Note: Authority cited: Section 100504, Government Code. Reference: Sections 100502 and 100503, Government Code; and 45 CFR Section 155.420.

 

Health & Safety Code 1399.849 (d)   
Virtually the same rules

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(b) Loss of MEC, (Minimum Essential Coverage)

as specified in subdivision (a)(1)(A) of this section, includes:

(1) Loss of eligibility for coverage, including but not limited to:

(A) Loss of eligibility for coverage as a result of:

1. Legal separation,

2. Divorce or dissolution of domestic partnership,

3. Cessation of dependent status (such as attaining the maximum age to be eligible as a dependent child under the plan),

4. Death of an employee,

5. Termination of employment,

6. Reduction in the number of hours of employment, or

7. Any loss of eligibility for coverage after a period that is measured by reference to any of the foregoing;

(B) Loss of eligibility for coverage through Medicare, Medi-Cal, or other government-sponsored health care programs, other than programs specified as not MEC under 26 CFR Section 1.5000A-2(b)(1)(ii);

(C) In the case of coverage offered through an HMO or similar program in the individual market that does not provide benefits to individuals who no longer reside, live, or work in a service area, loss of coverage because an individual no longer resides, lives, or works in the service area (whether or not within the choice of the individual);

(D) In the case of coverage offered through an HMO or similar program in the group market that does not provide benefits to individuals who no longer reside, live, or work in a service area, loss of coverage because an individual no longer resides, lives, or works in the service area (whether or not within the choice of the individual), and no other benefit package is available to the individual; and

(E) A situation in which a plan no longer offers any benefits to the class of similarly situated individuals that includes the individual.

(2) Termination of employer contributions toward the employee’s or dependent’s coverage that is not COBRA continuation coverage, including contributions by any current or former employer that was contributing to coverage for the employee or dependent; and (3) Exhaustion of COBRA continuation coverage, meaning that such coverage ceases for any reason other than either failure of the individual to pay premiums on a timely basis, or for cause, such as making a fraudulent claim or an intentional misrepresentation of a material fact in connection with the plan. An individual is considered to have exhausted COBRA continuation coverage if such coverage ceases:

(A) Due to the failure of the employer or other responsible entity to remit premiums on a timely basis; (B) When the individual no longer resides, lives, or works in the service area of an HMO or similar program (whether or not within the choice of the individual) and there is no other COBRA continuation coverage available to the individual; or (C) When the individual incurs a claim that would meet or exceed a lifetime limit on all benefits and there is no other COBRA continuation coverage available to the individual.

(c) Loss of coverage, as specified in subdivision (a)(1) of this section, does not include voluntary termination of coverage or loss due to:

(1) Failure to pay premiums on a timely basis, including COBRA premiums prior to exhaustion of COBRA coverage; or (2) Termination of coverage for cause, such as making a fraudulent claim or an intentional misrepresentation of a material fact in connection with a plan.

 

Email clarification from Covered CA Broker Support

Hi Steve,

Basically the children lost subsidy eligibility because they actually qualify for Medi-Cal so they were removed from the policy. Unfortunately, even though this would seem to be an involuntary loss of coverage, it’s not considered a Qualifying Event because the children are not losing coverage; [minimum essential coverage] they are merely losing the private insurer coverage they preferred and instead getting state-sponsored Medi-Cal coverage. If later the children are denied Medi-Cal or lose eligibility for Medi-Cal, either situation would be a Qualifying Event. Email dated 9.12.2016 5:01 PM from a major insurance company manager

Adverse selection  a situation where an individual’s demand for insurance is positively correlated with the individual’s risk of loss.

Certify Special Reason under penalty of Perjury

(d) A qualified individual or an enrollee shall attest under penalty of perjury that he or she meets at least one of the triggering events specified in subdivision (a) of this section. The Exchange shall inform the qualified individual or the enrollee that pursuant to 45 CFR Section 155.285, HHS may impose civil money penalties of:

(1) Up to $25,000 on the qualified individual or the enrollee who fails to provide the correct information requested by the Exchange, subject to the exception specified in subdivision (e)(4) of this section, due to his or her negligence or disregard of the federal or State rules or regulations related to the Exchange with negligence and disregard defined as they are in section 6662 of IRC (26 USC § 6662), as follows:

(A) “Negligence” includes any failure to make a reasonable attempt to provide accurate, complete, and comprehensive information; and (B) “Disregard” includes any careless, reckless, or intentional disregard for any federal or State rules or regulations related to the Exchange; and

(2) Up to $250,000 on the qualified individual or the enrollee who:

(A) Knowingly and willfully provides false or fraudulent information requested by the Exchange, where knowingly and willfully means intentionally providing information that the person knows to be false or fraudulent; or

(B) Knowingly and willfully uses or discloses information in violation of Section 1411(g) of the Affordable Care Act (42 USC § 18081(g)), where knowingly and willfully means intentionally using or disclosing information in violation of Section 1411(g).

10 CCR § 6492  California Code of Regulations

§ 6492. Inconsistencies.
.
(a) Except as otherwise specified in this Article, for an applicant whose attestations are inconsistent with the data obtained by the Exchange from available data sources, or for whom the Exchange cannot verify information required to determine eligibility for enrollment in a QHP, or for APTC and CSR, including when electronic data is required in accordance with this section but data for individuals relevant to the eligibility determination are not included in such data sources or when electronic data from IRS, DHS, or SSA is required but it is not reasonably expected that data sources will be available within one day of the initial request to the data source, the Exchange:
.
(1) Shall make a reasonable effort to identify and address the causes of such inconsistency, including through typographical or other clerical errors, by contacting the application filer to confirm the accuracy of the information submitted by the application filer;
.
(2) If unable to resolve the inconsistency through the process described in subdivision (a)(1) of this section, shall:
.
(A) Provide notice to the applicant regarding the inconsistency; and
.
(B) Provide the applicant with a period of 95 days from the date of the notice described in subdivision (a)(2)(A) of this section to either present satisfactory documentary evidence through the channels available for the submission of an application, as described in Section 6470(j), except by telephone, or otherwise resolve the inconsistency.
.
(3) May extend the period described in subdivision (a)(2)(B) of this section for an applicant if the Exchange determines on a case-by-case basis that the applicant has demonstrated that he or she has made a good-faith effort to obtain the required documentation during the period.
(4) During the period described in subdivision (a)(2)(B) of this section, shall:
(A) Proceed with all other elements of eligibility determination using the applicant’s attestation, and provide eligibility for enrollment in a QHP if an applicant is otherwise qualified; and
(B) Ensure that APTC and CSR are provided within this period on behalf of an applicant who is otherwise qualified for such payments and reductions, as described in Section 6474, provided that the tax filer attests to the Exchange that he or she understands that any APTC paid on his or her behalf are subject to reconciliation.
(5) If, after the period described in subdivision (a)(2)(B) of this section, the Exchange remains unable to verify the attestation, shall: (A) Determine the applicant’s eligibility based on the information available from the data sources specified in Sections 6478 through 6492, unless such applicant qualifies for the exception provided under subdivision (b) of this section; and
(B) Notify the applicant of such determination in accordance with the notice requirements specified in Section 6476(h), including notice that the Exchange is unable to verify the attestation.
(6) When electronic data to support the verifications specified in Section 6478(d) or Section 6480 is required but it is not reasonably expected that data sources will be available within one day of the initial request to the data source, the Exchange shall accept the applicant’s attestation regarding the factor of eligibility for which the unavailable data source is relevant.
(b) The Exchange shall provide an exception, on a case-by-case basis, to accept an applicant’s attestation as to the information which cannot otherwise be verified and the applicant’s explanation of circumstances as to why the applicant does not have documentation if:
(1) An applicant does not have documentation with which to resolve the inconsistency through the process described in subdivision (a)(2) of this section because such documentation does not exist or is not reasonably available;
(2) The Exchange is unable to otherwise resolve the inconsistency for the applicant; and
(3) The inconsistency is not related to citizenship or immigration status.
(c) An applicant shall not be required to provide information beyond the minimum necessary to support the eligibility and enrollment processes of the Exchange, Medi-Cal, and CHIP.
Note: Authority cited: Section 100504, Government Code. Reference: Sections 100502, 100503 and 100504, Government Code; and 45 CFR Section 155.315.

Effective Dates

(g) Except as specified in subdivision (h) of this section, regular coverage effective dates for a special enrollment period for a QHP selection received by the Exchange from a qualified individual:

(1) Between the first and fifteenth day of any month, shall be the first day of the following month; and (2) Between the sixteenth and last day of any month, shall be the first day of the second following month.

(h) Special coverage effective dates shall apply to the following situations.

(1) In the case of birth, adoption, placement for adoption, or placement in foster care, the coverage shall be effective either:

(A) On the date of birth, adoption, placement for adoption, or placement in foster care; or

(B) On the first day of the month following the date of birth, adoption, placement for adoption, or placement in foster care, at the option of the qualified individual or the enrollee.

See our webpage on adding newborns
Also double check the rules for each company in the side margins above

For example:  Kaiser’s Rule

Your coverage will start on the date of birth, adoption, foster care, or placement for adoption or foster care, or the first day of the month after we receive your application, whichever option you choose.

(2) In the case of marriage or entry into domestic partnership, the coverage and APTC and CSR, if applicable, shall be effective on the first day of the month following plan selection.

(3) In the case where a qualified individual, or his or her dependent, loses coverage, as described in subdivisions (a)(1) [Loss of MEC, non calendar year coverage, Medi-cal] and (a)(8) [ineligible for employer group coverage] of this section, the coverage and APTC and CSR, if applicable, shall be effective:

(A) On the first day of the month following the loss of coverage if the plan selection is made on or before the date of the loss of coverage; or (B) On the first day of the month following plan selection if the plan selection is made after the date of the loss of coverage.

(4) In the case of a qualified individual or enrollee eligible for a special enrollment period described in subdivisions (a)(5), (a)(6), (a)(11), (a)(13), or (a)(14) of this section, the coverage shall be effective on an appropriate date, including a retroactive date, determined by the Exchange on a case-by-case basis based on the circumstances of the special enrollment period. (5) In the case of a court order described in subdivision (a)(2)(A) of this section, the coverage shall be effective either:

(A) On the date the court order is effective; or (B) In accordance with the regular coverage effective dates specified in subdivision (g) of this section, at the option of the qualified individual or the enrollee.

(6) If an enrollee or his or her dependent dies, as described in subdivision (a)(2)(B) of this section, the coverage shall be effective on the first day of the month following the plan selection.

Insure Me Kevin.com on being careful with Covered CA about effective date and enrollment reason selection

Historical

FLASH –

Due to Corona Virus –

You can now enroll if you didn’t have coverage!!!  

Deadline extended to August 31st (Sharp)

Covered CA 7.29.2020 Press Release

 

corona virus option

See button above or below to get quotes

After you get your quote, see button below to set a meeting time to go over the quotes and submit your application.

 

IMHO the way things are worded and advertised, is misleading.  I’m ashamed to be involved with Covered CA.  Mr. Peter Lee at an agent meeting threatened to terminate any agent involved in misusing a Special Enrollment period.   The Covid 19 special enrollment, when one reads the details says it’s for those who do not currently have coverage.  That’s not the advertisements I’ve seen, nor even what Covered CA shows on their enrollment form, above.

While we are at it, Covered CA, promised to give agents an affiliate link.   I’m not here to fill out applications.   I’m here to give extensive research and analysis of what coverage will work the best for you!

 

Insurance Application – Errors – What must be disclosed

JUST IN

If you didn’t know about the CA Mandate Penalty or the Subsidies to 600% there is a Special Enrollment Period just for you!

Click here for details

 

If your Health Sharing Ministry Plan just got a Cease & Desist Order, you may be eligible.  Review the rules about loss of coverage, get a quote  and email us.

Covered CA TV Ad about special enrollment if you didn’t know about the CA Mandate Penalty or Subsidies to 600%

Covered CA TV ad

I resent that Covered CA does not mention one can use an agent at no extra charge!

Get an Instant Quote & Subsidy Calculation

What if an Insurance Company or Covered CA makes a material mistake, error on a provision etc.
Does that give you a chance to re-enroll to fix the problem?

 

(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:

(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 of an officer, employee, or agent of the Exchange or HHS, its instrumentalities, or a non-Exchange entity providing enrollment assistance or conducting enrollment activities. For purposes of this provision, misconduct includes the failure to comply with applicable standards under this part, part 156 of this subchapter, or other applicable Federal or State laws as determined by the Exchange.

♦ Pending Litigation and DOI Investigation – Narrow MD lists

Appeal ruling I found in a google search

(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;

(MD lists incorrect or not available?)

(Details 155.420

Covered CA NOT requiring documentation 

♦ Oops, now they are

♦ Lawsuit alleging Fraud to gain market share  

Medical Provider drops out of Health Plan   

More 

[Rx not on Formulary?]

Resources & Links

Our Covered CA Appeals Page

 

Anonymous says:
I let my Coverage go because President Trump said that it was no good, illegal, unconstituonal, etc. I now want to get coverage as CA has brought back the mandate penalty.

 

Would this qualify as an error, material violation, etc. so that I don’t have to wait for open enrollment?

 

19 comments on “Special Enrollment Periods Covered CA & Direct with Broker

  1. Hi Steve…

    I was offered a new job…and the project has been delayed for up to 4 months.

    We have no income coming into the house with the Covid 19 thing going on…I want to see if we can cancel our current plan and get a policy and subsidies through Covered California until my new project gets going….then we will have health ins through my employer.

    Thank Steve…let me know what you need from us.

    Hope you are staying virus free and healthy.

    Hugs

    Robin

  2. Is there a penalty or even a possibility to change levels on my insurance?

    This $1222 for a Silver HMO, age 60 to 65 is killing me.

  3. Does Employer’s Open Enrollment in June – Allow dependents to have open enrollment into Individual Market?

  4. 1. What is the cost of your health insurance?

    …..A How does it compare to the COBRA offer I uploaded privately to you?

    2. What happens if I get a new job in 20 days.
    …..A What are the payment terms with your company?

    3. Basically how does this insurance work since I am between jobs.

    4. When does your insurance start once I sign up?

    • 1. You can get quotes, pricing, benefits and enroll online 24/7 by clicking here.

      …A I’ll send you a private email on that.

      4. As long as you enroll by the end of the month, it would be effective the first of the month, when you lose MEC Minimum Essential Coverage. Double check as different special enrollment reasons have different deadlines. Most of the time you have to enroll by the 15th to get first of the month. If you want till the end of the month to enroll, we will not be happy campers if you call and ask where your ID cards are on the 1st of the month. Learn More

      3. You buy the plan. When you get new coverage, you cancel the plan.

      2. Then I wasted my time…and you cancel the coverage when your new employer coverage starts.
      ….A You pay the first premium with the application. Then you get billed or automatic payments direct with whatever Insurance Company from # 1 that you choose.

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