Next Monday is the last day of open enrollment for Marketplace health insurance coverage. Open enrollment is the window of time in which any person can enroll for coverage in the Marketplace. Once open enrollment closes it will not stop enrollment altogether. People can still enroll during “special enrollment periods,” a 60-day period following the occurrence of some life event that results in loss of person’s insurance. It can also be triggered by the change of a person’s eligibility for coverage on the Marketplace.
Promptly determining if you are entitled to special enrollment is important because without special enrollment you can not obtain coverage on the Marketplace until the next open enrollment period. Currently the next open enrollment period is Nov. 15 through Jan. 15, 2015. If you are eligible for open enrollment you can apply for financial assistance for paying your premiums as well as deductibles and co-pays subject to the same rules as during open enrollment. The following events trigger special enrollment periods:
• Losing your own or dependents other minimum essential coverage that was provided by employment. This might be from job loss or because the employer no longer provides the coverage. A person might have to use available COBRA coverage if this cost is less than 8 percent of their earnings, but often, especially after a job loss this is not affordable. It does not matter if you are laid off or fired for cause. In either event you can get coverage on the marketplace.
• Sometimes a person will lose coverage because of a change in age, as when a child turns 26 and can no longer be covered on their parent’s policy, or a child on Healthwave turns 18 (or sometimes 20) and loses CHIP coverage. This creates a special enrollment period.
• A divorce can cause the loss of health insurance coverage. Again the availability of affordable (less than 8 percent of income) COBRA coverage needs to be considered. Also, dependents may become eligible from marriage, birth, or adoption.
• Because Kansas has not adopted Medicaid expansion, some Kansans actually earn too little to qualify for subsidies. If their income goes up, they should apply for coverage under a special enrollment period. Because this was not anticipated under the law, you should get a Navigator to help you with this one. Also, it is important to obtain a “waiver” indicating you have been determined to be ineligible for a subsidy. Again, get help from a Navigator on this one.
• Likewise, it is a special circumstance if someone who was previously ineligible for financial assistance or only received limited assistance experiences a loss of income that makes them eligible for coverage or a larger subsidy.
• A person who was not lawfully present or so called “illegal aliens” who gain lawful status have a special enrollment period upon receiving the legal status.
• A citizen or lawful immigrant who returns from an absence from the country has a special enrollment period when they return to the USA.
• Some people who have attempted to enroll in the Marketplace were diverted to Medicaid (Kancare) or Healthwave for a determination of whether they were eligible for those programs. If they are found ineligible, they have a special enrollment period beginning upon their determination from these programs.
• A person covered by an insurance plan that fails to live up to standards under the ACA has a special enrollment period if the insurer fails to provide required coverage.
• A person released from incarceration has a special enrollment period commencing upon release.
• A Native American can enroll at any time.
• There is also a catch-all provision saying “enrollee meeting other exceptional circumstances, as determined by the Exchange or HHS” has a special enrollment period upon being granted the exception.
You do NOT receive a special enrollment period if you lose Marketplace coverage for failure to pay your share of the premiums.
Like many things on the Marketplace, we might be in for some surprises. Up to this point, all enrollment on Marketplace has been based on open enrollment. There does not seem to be a feature on Healthcare.gov that handles special enrollment. I looked for a paper application for special enrollment and could not find one either. Presumably these matters will be shortly sorted out. If you need any help feel free to call Thrive Allen County at 365-8128. We will still be there and will help you with special enrollment too.
— John Robertson