If you are diagnosed with a critical illness during the year, that is not a Qualifying Life Event for a Special Enrollment Period (SEP) to change health plans. In most health plan situations, you must stay with your current health plan until the open enrollment period for the next plan year.
Most people with no health challenges will select a health plan based on the lowest monthly premium. There is nothing wrong with this strategy as most health plans have an annual maximum out-of-pocket amount that limits your exposure to health care expenses during the year.
Changing Health Plans with Critical Illness Diagnosis
This strategy comes into doubt when you are diagnosed with a critical illness that needs extensive health care treatment. After the open enrollment period closes, you are generally stuck with the plan you have selected for the remainder of the year. Being diagnosed with an intractable health care challenge is not a Qualifying Life Event for a Special Enrollment Period to change health plans.
Not all health plan segments have the exact same rules. Some health plan markets may have different rules that you can use to your benefit if you are diagnosed with a critical illness.
Medi-Cal Open All Year
If you have NO health insurance and NO or low income.
- In California, Medi-Cal is open all year. If your monthly household income is below 138 percent of the federal poverty level for your household size, you can enroll in a no cost Medi-Cal HMO plan. You must either be a U.S. citizen or have the correct immigration status.
- If you did not enroll in a health plan during open enrollment AND your income is over 138 percent of the federal poverty level for your household size, you can’t enroll in an individual and family plan
Individual and Family Plans
Covered California
- Once the Open Enrollment Period closes you cannot change your health plan.
- Income SEP: If your income decreases and you are enrolled in a Silver 70 plan, you might be offered an enhanced Silver 73, 87, or 94 health plans with the same carrier. The enhanced Silver plans will lower your cost-sharing for health care services.
- Address Change SEP: If you must move because of your illness and your existing health plan is not offered, then you could change health plan and metal tier.
Off-Exchange
- If you have enrolled with a health plan off-exchange, direct with the carrier, and Open Enrollment has closed you cannot change plans.
- Address Change SEP: If you move because of the illness and the health plan is not offered at your new address, you could enroll in a new health plan.
Employer Group Plans
In general, with employer group plans, you are locked into the health plan you selected during open enrollment. However, because there are a variety of employer plans (small group, large group, self-funded employer plans, union) check with your human resources department to see if there is any wiggle room for changing plans.
Medicare Advantage
Medicare Advantage plans are similar to the other health plan segments. Once open enrollment is closed you cannot change your plan until the next Annual Enrollment Period. There are few caveats to this rule.
- 5-Star Plan SEP: You can switch to a 5-Star Medicare Advantage plan once outside of the Annual Enrollment Period if you are not already in the plan.
- Chronic Illness SEP: If you are diagnosed with a chronic illness AND there is a Chronic Illness Special Needs Plan (C-SNP) in your county for your specific illness, you may be able to change plans.
- Medicare & Medi-Cal SEP: If you are dually eligible for Medicare and Medi-Cal, you change your Medicare Advantage plan after the Annual Open Period has closed to a Dual Special Needs Plan (D-SNP).
Under 65 Medicare SEP
- If you have been diagnosed with End Stage Renal Disease (ESRD) or Amyotrophic Lateral Sclerosis (ALS) you will become eligible for Original Medicare Parts A and B.
- There are other chronic illnesses that leave you disabled by Social Security definitions and may allow you to gain temporary or permanent Medicare benefits.
There are a couple reasons why people would like to change health plans when they receive a diagnosis of a critical illness
- The cost of health care services.
If you have enrolled in a Bronze metal tier plan, you may have to pay the full negotiated rate for a variety health care services before you meet the plan deductible. This may mean a lot of money upfront for laboratory tests, diagnostic tests, x-rays, MRIs, CT and PET scans, outpatient procedures and possibly hospitalization.
The good news is that your health plan has a maximum out-of-pocket amount that once met, the health plan covers the cost of all health care services for the remainder of the year. Had you selected a Silver metal tier plan, or higher, you would have a higher monthly premium. The Silver plan would lower your out-of-pocket costs for many of the health care services, but the higher plan premium may be more than the savings.
However, a Silver plan is better if you know that you will be enduring multiple office visits, tests, imaging, procedures, combined with prescription medications. A Silver, Gold, or Platinum should be considered during the Open Enrollment Period if anticipate the health care services for your chronic illness will continue into the next plan year.
2. Access to other providers outside of the health plans network.
Initially, you may have selected the least expensive Bronze HMO plan with a narrow network of providers such as doctors and hospitals. Not having access to highly rated medical groups and hospital facilities is the main reason why people want to switch plans after being diagnosed with a critical illness.
Through research, you might learn of medical group that specializes in treatments for your particular illness. Unless you can convince your HMO plan to refer you to that medical group, the health plan won’t cover the health costs of those out-of-network providers. Always ask your primary care physician to attempt to refer you to an out-of-network provider. There are health plans who will make the referral depending on the disease or illness and cover the health care costs.
Finally, if you find your health plan expects you to pay too much for health care services and does not have the specialists you want in the network, don’t get mad at yourself. No one can anticipate the development of a chronic illness. You made a health plan decision on the best information you had at the time. During the Open Enrollment Period you will be able to change health plans to one that matches your health care needs.
You Tube video on Chronic or Critical Illness Plan Changes.
