Yesterday, August 13, CMS.gov announced nearly one million Americans qualified with a “qualifying life event” and enrolled for health insurance coverage through the federal exchange from Feb. 23 through June 30, 2015. A life event, such as having a baby or getting married, is required outside of Open Enrollment in order to receive ACA/Obamacare medical coverage. Here’s the breakdown of qualifying events provided by CMS:
“Life changes are often impossible to predict, but access to affordable and quality health care coverage should never be,” says Kevin Counihan, CEO of the Health Insurance Marketplace. “So far this year, nearly 950,000 people have gained the peace of mind that comes with access to coverage by taking advantage of a special enrollment period, providing us with further evidence that the Health Insurance Marketplace is working for America’s families.”
These numbers are the first released since the Supreme Court’s decision to uphold the Affordable Care Act’s (ACA’s) health insurance subsidies in all 50 states. This extended time window has helped the total number of uninsured Americans fall below 10 percent, as evidenced by two recent surveys.
- The National Health Interview Survey found that 7 million fewer people were uninsured in the first three months of this year, compared to 2014’s entire average. The uninsured rate stood at 9.2 percent.
- The Gallup-Healthways Well-Being Index found a statistically significant drop in most states’ uninsured rates, since the law’s big coverage push began at the end of 2013. States that embraced the Medicaid expansion saw bigger declines.
Beneficiaries generally enroll during the annual open enrollment period (OEP), which begins on Nov. 1, with new coverage starting on Jan. 1, 2016. However, many individuals and families may fail to enroll during this OEP, placing them at risk for financial penalties. But for these new and existing beneficiaries, the special enrollment period provides additional time to select insurance plans and avoid coverage gaps.
How to qualify for an SEP
The large number of consumers signing up for coverage during the SEP illustrates this extended period’s need and value for potential Marketplace consumers. Generally, individuals and families experiencing either a qualifying life event (QLE) or a change in circumstance enroll during these extended windows. Typically, SEPs run for 60 days from the date of the enrollee’s qualifying event (examples are provided below). Among the possible qualifying situations for SEPs are:
- Changes to health coverage, including changes to or losing employer-sponsored or private insurance.
- Changes to Medicaid or CHIP coverage, including being determined to be ineligible for these programs. Children’s Health Insurance Program is a joint federal-state program providing health insurance for low-income children.
- Changes affecting Marketplace plans, including not being enrolled or enrolling in the wrong plan. You may also be affected by plan contract violations.
- Changes in family status, including marriage, divorce, childbirth or adoption, child support or court order
- Changes in income affecting payment for coverage, including qualifying or disqualifying for subsidies.
- Experiencing domestic abuse, violence or spousal abandonment; i.e., you may want to enroll in your own health plan separate from your abuser or abandoner.
- Experiencing a hardship preventing enrollment during the 2015 Open Enrollment Period; i.e., natural disaster, serious medical condition
- Changes in citizenship, including gaining status as a citizen, national or lawfully present individual. One particular area of focus is gaining or maintaining status as a member of a federally recognized tribe or Alaska Native Claims Settlement Act (ANCSA) Corporation shareholder.
- Relocating to a new state; specifically, one that hasn’t expanded Medicaid. If so, you may qualify for help paying for coverage. Or, there may be new Marketplace health plan choices in your new state.
The distribution of 2015 SEP enrollment
Research shows that 84 percent of consumers purchased coverage through Federally Facilitated Marketplaces (FFMs) during an SEP, likely due to three main reasons. FFMs are organized marketplaces for health insurance plans operated by the U.S. Department of Health and Human Services (HHS). SEPs only apply to the 37 states covered by the federal marketplace; however, some state-run exchanges also enable consumers to take advantage.
According to the researchers, from February 23 to March 14 (before the SEP’s start) there were about 5,000 plan selections a day. But on April 30th, the SEP’s last day, more than 38,000 plan selections were made. As the following table shows, 50 percent enrolled through an SEP due to the loss of health coverage or “minimum essential coverage.” Another 19 percent enrolled due to being determined ineligible for Medicaid, while15 percent enrolled as a result of the tax season. Additionally, SEP enrollees are typically younger than those enrolling during the OEP. Researchers found that the Marketplace has proved effective in ensuring continuity for younger consumers’ coverage.
It’s important to know that open enrollment restarts on November 1st, 2015. All Americans must enroll in health insurance or face a tax penalty of $695 per adult for 2016.