Affordable Care Act

How to get healthcare coverage now with a Special Enrollment Period

Est. 4 min read

There are many joys that come with working at PolicyGenius. We have snacks, we crush New York City at trivia nights, and several of my co-workers also appreciate the musical stylings of Steely Dan, Bell Biv Devoe and MC Hammer. My favorite, however, is that I get to use my own life experiences to educate people about life and health insurance, which is why I want to talk about my feet.

If you move to New York City, you’re going to walk everywhere. I’m putting in 5+ miles a day, and my feet hurt. I could schedule an appointment with a podiatrist, but instead, I’m probably just going to buy some $100 Nikes and some Dr. Scholl’s inserts on payday. But if they keep hurting, I’ll go see a podiatrist eventually.

But what if you’re in the same boat as me, but you don’t have insurance? You could buy one of the policy types I wrote about here – if available in your state. You could do what some New Yorkers are doing – negotiate discounts and pay cash. Or you can wait until November 1, 2016 for the Healthcare Open Enrollment window to open, and then wait until January 1, 2017 to be covered. But, that doesn’t really solve your “now” problem, does it?

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No: if you want health insurance now, and you want to buy it from your state’s official health insurance marketplace, you have to qualify for a Special Enrollment Period. On Healthcare.gov, there is a tool that will help you determine if you likely do qualify. And then it asks you to complete or update an application for coverage, where you’ll get a “final decision” on if you do qualify for that Special Enrollment Period.

Here are the most common triggers of a Special Enrollment Period:

  • Getting Married or Divorced
  • Having a baby, adopting a child, or placing a child into adoption or foster care
  • Moved to a new residence
  • Gaining Citizenship or “lawful presence in the US”
  • Leaving incarceration
  • Losing other health coverage

Most of these are pretty self-explanatory, but the following are the ones that need explaining, since the general answer to the “Can I change my plan” question for these scenarios is: “Maybe.”

Let’s say you had Kaiser Permanente when you lived in San Francisco’s Marina district. You’re thinking about moving to South Lake Tahoe, California – 190 miles away, where Kaiser Permanente is not available. Since your plan isn’t available, you qualify for a Special Enrollment Period.

Now let’s make the move locally. Instead of moving to Tahoe, you’re going to stay in San Francisco, and move from the Marina District to Ocean Beach. At your new address, your Kaiser plan exists but has changed in some way – it went up in price, for example, or increased the co-pay. Since the plan has changed due to your move, you qualify for a Special Enrollment Period.

Lastly, and this is easiest one, if you move to another county or another state, you automatically qualify for a Special Enrollment Period, regardless of whether the same plan is available or if it has changed at all.

(Thanks to Garrett with Covered California for letting me run various moving scenarios past him.)

If you lost other health coverage, that will trigger a Special Enrollment Period, depending on the circumstances:

Special Enrollment Allowed:

  • Your employer ends its group plan with no replacement
  • You resign your employment
  • You’re laid off or fired
  • You opt out of employer coverage during open enrollment
  • You’re turning 26 and are losing coverage under a parent’s plan
  • You’ve lost Medicaid or Children’s Health Insurance Program
  • You’re losing coverage because of divorce
  • You’ve used your 18 months (or 36 months, in some states and situations) of COBRA

Special Enrollment Not Allowed:

  • You canceled your COBRA
  • Your employer paid your COBRA and you decided to discontinue that coverage when it stopped
  • You were terminated for non-payment of premiums

Non-payment of premium does not qualify as a Special Enrollment since it’s not an “involuntary loss of coverage.” Even if your (former) employer pays your COBRA for a few months as part of a severance agreement, or your best friend’s cousin’s aunt is making that Blue Cross payment, it’s still your responsibility to do so, and if you don’t, your coverage is lost.

If you lost your coverage because of non-payment of premiums, call your carrier and ask if it’s possible to reinstate. You may have to pay retroactive premiums, but if it’s possible, you’ll have the same coverage you had before. Likewise, if you can no longer afford your premiums because of a change in your income, contact your county or state Health and Human Services department to see about getting Medicaid (Medi-Cal in California). Getting or losing Medicaid counts towards Special Enrollment.

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So now that you’ve checked to see if you’re eligible, what’s next? If you are, and you bought a plan through the “Marketplace” (exchanges), you log into your account, report the qualifying life change, select your new plan and upload your proof (divorce decrees, marriage licenses, termination letters from your carrier, etc.).

If you didn’t buy from the exchange for your area, consult that area’s exchange or the private marketplace you bought a plan from.

And with that, you can finally see the podiatrist so your feet don’t hurt. But one note of caution: you’re probably going to pay out of pocket for those custom shoe inserts since most carriers don’t cover them.

Image: Jeff Eaton

Published on August 5, 2015

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Otis Boone is the Senior Client Service Representative at PolicyGenius, a digital insurance brokerage trying to make sense of insurance for consumers. You can find him on LinkedIn.
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