Qualifying Life Events for Special Enrollment

One of the biggest selling points of the Affordable Care Act was that it would allow millions who previously had not had insurance to get affordable insurance through a public health insurance exchange. The biggest benefactors primarily included:

1. Those without an employer plan who had pre-existing conditions

2. Those who could not afford a plan on their own due to income, age, or some combination of the two

And between Medicaid expansion and the health insurance exchange (paired with subsidies), the ACA has greatly reduced the uninsured rate.

healthcare enrollment qualifying life eventBut now that open enrollment has closed, what if life (shit) unpredictably happens, as it often does, and you have a massive life changing event and need insurance coverage?

There’s always good ole COBRA, if you leave your job and want to extend your employer’s insurance plan. But it’s typically way overpriced. You can check out your W2, box 12, code DD to find out how much your employer and you (through premiums) are paying for your insurance plan. With COBRA, you’d pay that (broken down in to monthly premiums), plus up to an additional 2% admin fee. COBRA can last up to 18 months, if you are eligible.

As I discovered, your employer’s insurance plan can be way overpriced, which could make COBRA cost prohibitive for you. Then what?

The ACA marketplace open enrollment now only runs from the beginning of November to mid December for most states. That means everyone who wants to sign up for insurance has three months to do it, and nine other months where they cannot. Thankfully, there are exceptions.

For starters, if you are eligible, you can apply and enroll in Medicaid or the Children’s Health Insurance Program (CHIP) any time. There is no limited open enrollment period for these programs. Also, members of federally recognized tribes and Alaska native shareholders are eligible to enroll any time.

If you don’t fall in to one of those categories, then what?

You can still apply and enroll for a plan outside of open enrollment through a special enrollment, at any time. But in order to do so, you need to have a qualifying life event (QLE). Example qualifying life events include:

  • Marriage
  • Having a baby
  • Adopting a child or placing a child for adoption or foster care
  • Moving to a new home in a new ZIP code or county
  • Moving to the U.S. from a foreign country or United States territory
  • If you’re a student, moving to or from the place you attend school
  • If you’re a seasonal worker, moving to or from the place you both live and work
  • Moving to or from a shelter or other transitional housing
  • Losing other health coverage—due to losing job-based coverage, divorce, the end of an individual policy plan year, COBRA expiration, aging off a parent’s plan, losing eligibility for Medicaid, Medicare, or CHIP, and similar circumstances. Voluntarily ending coverage doesn’t qualify you for a special enrollment period. Neither does losing coverage that doesn’t qualify as minimum essential coverage.
  • Gaining citizenship
  • Leaving incarceration
  • Gaining status as member of an Indian tribe. Members of federally recognized Indian tribes can sign up for or change plans once per month throughout the year.
  • For people already enrolled in Marketplace coverage: Having a change in income or household status that affects eligibility for premium tax credits or cost-sharing reductions

There could be other circumstances that would make you eligible, but you’d have to apply or call and speak to a rep at 1-800-318-2596.

Outside of life qualifying events, you’re on your own. You can still find a “short-term” health insurance plan on a private exchange or directly with insurance providers – but you won’t be eligible for a subsidy, and you may still have to pay the individual mandate penalty because these plans are not considered minimum essential coverage. They are also not guaranteed-issue and do not cover pre-existing conditions.

Good stuff to know for when life happens. And it will eventually. Discussion:

  • Did you sign up for a health insurance marketplace plan? Under what circumstances?
  • Have you been happy with your plan thus far?
  • Do you expect a qualifying life event this year that might lead to you signing up for a plan through the health insurance marketplace?

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