Special Enrollment Period

Posted by Phil Dougherty
April 25, 2016

The ACA reform has brought with it restrictions on when individual health insurance plans can be purchased. Every year there is an open enrollment period during which time those who are uninsured can enroll in a plan or those with a plan can make a plan change. The open enrollment period this year is November 1, 2016 through January 31, 2017. Outside of this open enrollment period, you’d need to experience a “qualifying life event” to enroll in coverage.

A qualifying life event initiates eligibility for a “Special Enrollment Period” (SEP) when you can enroll in any plan from any carrier offering plans in your region. Enrollment must take place within 60 days of the date of the qualifying event.

Here’s a list of the most common qualifying events:
–  Marriage
–  Divorce
–  Birth (adding a baby to an existing plan or enrolling the baby in an individual plan)
–  Loss of most employer-based coverage (i.e., resulting from retirement, lay-off or a dependent
turning age 26)
–  Exhausting all COBRA benefits
–  Becoming a new permanent resident of California (either moving from another state or from out of the country)

Note: Not having insurance is not in itself a qualifying event (unless you involuntarily lost coverage in the prior 60 days).

To successfully enroll during an SEP, documentation of the qualifying event must be submitted with the health plan application. Official documentation of a marriage, divorce, birth, or loss of group plan coverage is usually not difficult to obtain (certificates are issued for these), but they are not always available prior to the event, and coverage (except for newborns) cannot be made retroactive. Some carriers are easier to work with than others to make coverage effective sooner than later.

Some qualifying events are more challenging to prove than others. For example, a move to California from out of the country, whether by a US citizen returning from travel or by a new foreign resident, requires proof of permanent residency. Carriers will ask for copies of utility bills, or lease/rental agreements showing the applicant resides at the new California address. In some cases a copy of the applicant’s passport or visa showing an entry date will be needed or even proof of residency in the foreign country will be required. There are cases where documentation of these requirements is not readily available and, as a result, some carriers will refuse to accept enrollments until the annual open enrollment period. However, some carriers are more lenient than others and may accept an affidavit from a family member as proof of residency.

Additionally, some carriers may accept an application for special enrollment for circumstances that aren’t typical for SEP qualifying. For example, a rate increase on an individual grandfathered plan has been accepted by some carriers as a qualifying event.

Enrollees in Covered California, the public exchange, can also qualify by virtue of a loss of income or being newly eligible for Medi-Cal.

If you have questions or concerns about qualifying events or the Special Enrollment Period, we’ll be happy to talk with you.

Phil Dougherty