Presentation on theme: "Feb. 20, 2015 CAC Training WEBINAR Special Enrollment 1."— Presentation transcript:
Feb. 20, 2015 CAC Training WEBINAR Special Enrollment 1
2 Special Enrollment Period= Outside of Open Enrollment ( 2/16/15 to 9/30/15) Purpose – To understand the scope of enrollment time periods beyond open enrollment and to know what events qualify a client for SEP Process – Explain SEP and the enrollment time frame for qualifying events Payoff – Will be better able to seek out and enroll clients outside of open enrollment periods and able to make changes to an existing application
3 Special Enrollment EventsEffective Dates Household member lost or is going to lose MEC in past 60 days or will be losing in the next 60 days. 1 st of month following the date of the event A household member’s employer didn’t provide health coverage or the employer provided health coverage that wasn’t affordable or didn’t meet minimum value in the last 60 days. 1 st of month following the date of the event Household member got married in the last 60 days.1 st of month following the date of the event A household member gained eligible immigration status in the last 60 days. 15 day rule A household member moved in the last 60 days (to CT from another state, to a different county in CT) 15 day rule A household member had been adopted or placed for adoption in the last 60 days. Retroactive to date of adoption. Reporting window 60 days. Birth of household member in the last 60 days.Retroactive to the date of birth. Reporting window 60 days. Common SEP Events
4 Special Enrollment Period Policy that pertain to QHPs: The ACA states that Individuals cannot change or enroll in a new QHP outside of open enrollment unless a Special Enrollment qualifying event exists. In the individual marketplace, a consumer will have 60 days to report the qualifying event and choose a plan The 60 day special enrollment shopping period is determined by the event date, not reporting date If the applicant wishes to report an exceptional circumstance not covered by the Special Enrollment questions, he or she may appeal their Eligibility Determination
What happens if an individual does not report a birth or adoption within 60 days of the event? If an individual reports the change after 60 days of the event but within an open enrollment period: 15 day rule applies If an individual reports the change after 60 days of the event and open enrollment has ended: Individual must wait for the next open enrollment period. Applicant can file an appeal for exemption to AHCT by going to “Opt Out” on the homepage. What if The 60 Day Rule for Special Enrollment Events is not followed?
6 Exceptional SEP Events Exceptional Circumstances: – Error, misrepresentation, or inaction of an officer, employee, or agent of the Exchange or HHS, or its instrumentalities – QHP substantially violated a contract provision – Enrolled or not enrolled in the right plan; not enrolled in the QHP selected by the qualified individual or enrollee; or is eligible for but is not receiving APTC or CSR as a result of misconduct on the part of a non-Exchange entity providing enrollment assistance or conducting enrollment activities.
7 SEP policy for Death and Divorce The death of the primary applicant (i.e. the policy holder) would render the plan cancelled and the other members of the household can reapply during SEP with loss of MEC as the qualifying event. The remaining members will have to enroll in a new plan since the existing plan will be invalid. The death of a household member and the divorce of household members other than the Primary applicant are not considered Special Enrollment events. However, death or divorce of a household member who is not the primary applicant will change the household size and may cause changes in premiums and APTC, if applicable.
8 COBRA Coverage – While in open enrollment, a person can elect to stop COBRA coverage at any time and enroll in an exchange plan. Such person may also be eligible for cost- sharing or premium assistance. – Outside of open enrollment, COBRA coverage is considered MEC and a voluntary loss of MEC is not a qualifying event to shop for coverage on the exchange. However, COBRA can be dropped and a Special Enrollment Period opened up in two cases: 1.The employer ceases/reduces their contributions toward the former employee’s COBRA coverage and the coverage is no longer affordable so that the individual is newly eligible for APTC 2.When COBRA coverage terminates due to the maximum length of time allowable by law (a true loss of MEC) Depending on employment, COBRA can last 18 to 36 months
9 Non-Payment of Premium A consumer who loses their coverage due to non-payment of premium will not be able to apply on the exchange as this is considered a voluntary loss of coverage This event is not considered a qualifying event, and therefore the consumer will not be able to select a new plan at this time The consumer must wait until the next open enrollment period to enroll in coverage, unless they have a qualifying event
- 10 - A) APTC TO APTC OR B) QHP TO MEDICAID OR C) MEDICAID TO QHP OR D) MEDICAID TO MEDICAID During Special Enrollment period What happens when there are changes from…..
- 11 - A) Change from QHP/APTC to QHP/APTC during Special Enrollment A household enrolled in a QHP on the exchange that has a special enrollment event which allows everyone to open a Special Enrollment Period may take one of the following actions: o The family will have the opportunity to enroll in the same plan under the changed circumstances o The family may choose to enroll in a new plan from the same carrier or a new plan with a different carrier The Special Enrollment event allows the family the Special Enrollment shopping period. During this time they may make changes to their application Changes which are NOT qualifying events are treated as Change Reports and may affect APTC amounts and premiums. Changes to enrollment automatically go into effect as soon as the consumer Esigns, or a worker Submits the change report.
- 12 - B) Change from QHP to Medicaid during Special Enrollment A household enrolled in a QHP that reports a change which now qualifies them for Medicaid (i.e. change in income) will have an opportunity to select Medicaid, or a full priced Qualified Health Plan. If the consumer selects Medicaid, the system will send the 834 to the carrier with the disenrollment information. If the consumer selects to remain on a QHP plan, they will not be disenrolled, but will no longer have a tax credit.
- 13 - C) Change from Medicaid to QHP during Special Enrollment A household enrolled in Medicaid that reports a change which now qualifies them for a QHP or APTC (i.e an upward change in income) will automatically be disenrolled from Medicaid when they submit the change report application. The system will generate a change PDF to DSS with the disenrollment information when: o The consumer Esigns the change report application on the Consumer Portal o The worker clicks Submit on the change report application on the Worker Portal When the consumer is disenrolled, they will have coverage through the end of that month
- 14 - D) Change from Medicaid to Medicaid during Special Enrollment A household enrolled in Medicaid that reports a change which now qualifies them for a different sub program of Medicaid will be auto-enrolled to the new program when they submit the change report application. The system will generate a change PDF with the disenrollment information when: o The consumer Esigns the change report application on the Consumer Portal o The worker click Submit on the change report application on the Worker Portal. Consumers can be auto-enrolled interchangeably between Husky A, Husky D, and CHIP Band I. Consumers will not be auto-enrolled from any of these programs into CHIP Band II.
15 Reporting a Change or Qualifying Event After an initial application has been completed, a new link to “Report a Change” appears on the consumer’s account home screen. Once clicked, a list of 11 possible changes to report appears.
16 Best Practices for Reporting Changes When reporting a change, be sure to always proceed all the way to at least the determination screen. Otherwise, the change will not be considered complete and will not be processed. Best Practice Hint – If there is a link on the account homepage that reads “Continue Reporting a Change” then the change has not yet been completed If the change reported is not a qualifying event but does change APTC eligibility, such as a one time change in income such as an inheritance, the change will automatically transmitted to the carrier with new APTC Best Practice - DO NOT fiddle with income to test eligibility outcomes, these changes will be transmitted and might affect subsidies
Reporting a Qualifying Event during Special Enrollment – Practice Activity A family of 3 is currently enrolled in a QHP on the exchange and reports a change on 5/5 with the following special enrollment qualifying event: A second child was born on 4/16. What is the effective coverage date for each household member?
18 Reporting a Qualifying Event After Open Enrollment cont’d Effective coverage dates if the family stays on the same QHP Plan o Father: Effective coverage date of existing plan o Mother: Effective coverage date of existing plan o Child: Effective coverage date of existing plan o Newborn: 4/16 (DOB) Effective coverage dates if the family selects a new QHP Plan o Father: 6/1 (15 day rule) o Mother: 6/1 (15 day rule) o Child: 6/1 (15 day rule) o Newborn: 6/1 (15 day rule) The existing plan will cover the entire family through 5/31 and the new plan will start on 6/1 following the 15 day rule so there will be no gap in coverage
19 Knowledge Check: Changes and Coverage Effective Dates 1.On 2/16/2015 a consumer starts an application and reports that he will lose his employer’s coverage on 3/1/15. He completes the application and enrolls in an Anthem plan that same day. When will his new effective coverage date begin? 2.On 7/5/15 a consumer reports 2 qualifying events and receives a new coverage effective date of 7/1/15. If the events occurred on 6/1/15, what could the qualifying events be?
- 20 - – Answers 1.On 2/16/2015 a consumer starts an application and reports that he will lose his employer’s coverage on 3/1/15. He completes the application and enrolls in an Anthem plan that same day. When will his new effective coverage date begin? 4/1 (will lose MEC within next 60 days, 1 st of month following event) On 7/5/15 a consumer reports 2 qualifying events and receives a new coverage effective date of 7/1/15. If the events occurred on 6/1/15, what could the qualifying events be Loss of MEC OR marriage on 6/1 (within 60 days in past, 1 st of month following event)
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