Covered California has published a variety of documents explaining the Special Enrollment Period (SEP) for purchasing health insurance outside of the open enrollment period. Critical to being allowed to enroll in a health plan outside of open enrollment is having a qualifying life event to trigger a SEP. Those events include:
- Losing your current health insurance because of leaving employment, divorce, or moving to a region where your current plan is not offered
- Permanently moving to California, under certain circumstances you must have had health insurance in another state in the past 60 days.
- New born baby, adoption, or becoming a foster parent will allow the child to enroll outside of open enrollment and sometimes the parents.
- Recently got married or entered into a domestic partnership where the new partner can be added onto the other partners health plan.
- Returned from active duty military service
- Recently became a citizen or gained lawful presence
- Members of federal recognized American Indian or Alaska Native Tribe
60 Day Special Enrollment Rule
Within the Covered California system, if the individual or family are currently enrolled in health insurance through Covered California, reporting a change of income is also a qualifying event to change health plans in some situations. However, a significant decrease of income if the consumer is enrolled off-exchange (directly with a health plan or employer group) is not a qualifying event for applying for health insurance through Covered California with the Advance Premium Tax Credit monthly subsidies. Remember that the SEP only last for 60 days from the date of the event. If you try to enroll on day 61, the SEP will not be honored.
One exception to the 60-day rule is loss of minimum essential coverage (MEC). In these circumstances, consumer can apply 60 days before the loss, for a total of a 120-day period to report the qualifying event. The 60-day rule also does not apply to applications for Medi-Cal, which has open enrollment year-round.
Change of Income Qualifying Event
Covered California recommends reporting a change of income if the difference is more than 10% of the original estimate. This change of income can be a qualifying event inside of Covered California because only they can offer the Enhanced Silver Plans 73, 87, and 94, which are awarded based on the household income. For example, if an individual is in a Silver 94, and reports an increase of income, they may be eligible for the Silver 73. It also works the other way, reporting a decrease of income and becoming eligible for a Silver 94. The member cost-sharing is different between the plans. A change of income, qualifying event, can trigger a SEP to move to a different Enhanced Silver plan.
If the consumer stays with the same health plan carrier (Blue Cross, Blue Shield, Health Net, Kaiser, etc.) when they switch plans due to the income change, all the cost-sharing amounts the member has already spent accumulates in the new plan under the new plan benefits. If the consumer changes carriers, all the money they have spent on health care through the original plan is lost. All the deductibles reset to zero balance accumulation along with meeting the maximum out of pocket amount of the plan.
When reporting a change of income in Covered California, under the qualifying event SEP drop down menu, select “None of the Above”.
Other Qualifying Life Events For SEP
Not all qualifying life events or special circumstances are listed on the SEP drop down menu. For those not listed select “Other Qualifying Life Event.” You will need to provide of the evidence for the qualifying life event in the form of documentation. Some of the other qualifying life events can include the following.
- Health plan violates its contract
- Natural disasters and medical emergencies
- Pending Medi-Cal that is later denied
- Victim of domestic or spousal abuse
- Health plan failed to enroll the consumer because of data transfer issues
The date of the event will affect the start date of the health plan in combination with the type of qualifying life event. New babies and adopted children can get immediate coverage. Loss of coverage can be reported as the last day of the month, in which coverage is lost, and the start date will be the 1st of the next month. Generally, all other events require the submission of the application before the 15th of the month for an effective date of the 1st of the next month. https://www.coveredca.com/individuals-and-families/getting-covered/special-enrollment/qualifying-life-events/
Covered California is randomly contacting consumers who enrolled under a SEP to verify their qualifying life event. If documentation is not provided within 30 days, the health plan coverage can be terminated. The type of documentation requested will be dependent on the type of qualifying event for the SEP.
The Special Enrollment Period, Qualifying Life Events, and changes to income are VERY date sensitive. It can also be a little confusing in terms of what dates to use. If you don’t enter the correct dates, such as when income stopped or started, the application process can go sideways and you might be determined eligible for Medi-Cal. When in doubt, call your agent or the Covered California customer service line to determine the correct dates for your qualifying life event.