Opportunities to Purchase a Health Insurance Plan after Open Enrollment

The grid below comes from BCBS of IL (but applies to ALL states) and articulates what is considered a special enrollment, who is impacted, the timeline, and when a new policy would be effective. If you are unsure, ALWAYS talk to me as this chart doesn’t cover all circumstances.

NOTE: You can always purchase a Short Term Medical policy outside of open enrollment and special enrollment periods. Contact me for more information.

NOTE2: You can sign up for Medicaid at any time if you qualify (there are no enrollment periods).

Qualifying events can initiate a Special Enrollment Period (SEP) under the Affordable Care Act (ACA), and may allow your clients a window of time to select a new benefit policy or make a change to an existing policy. Here are events, enrollment dates and effective dates that may trigger an SEP. Categories that warrant special enrollment periods may be added in the future if other appropriate circumstances, as determined by CMS, become known.

Qualifying Event	Enrollment Period	Effective Date
Applicable to both Marketplace and non-Marketplace (on- and off-Exchange) Policies
Gaining/losing a dependent through birth/adoption/foster care/placement for adoption	60 days	Date of event
Gaining a dependent through marriage		First day of the following month after the event
Loss of Minimum Essential Health Coverage (MEC)*
Loss of eligible coverage from: Legal separation/divorce Cessation of dependent status (aging out) Death Termination or reduction of working hours with employer
Loss of coverage through an HMO due to relocation (applicable to both group and individual markets)
Incurs claim that meets or exceeds lifetime limits on all benefits
COBRA coverage ends
Employer ceases contributions either to subscriber or dependents	60 days	First day of the following month after the event
Permanent move		If the selection of the plan happens between first and fifteenth – the effective date is the first of the next month. If the selection of the plan happens after the fifteenth – the effective date is the first of the second following month.
Newly eligible/ineligible for advanced payments of tax credits or change in eligibility from cost-sharing reductions
Qualified Health Plan (QHP) substantially violates a material provision of its contract
Enrollment in QHP is made in error
Applicable to non-Marketplace (off-Exchange) Policies Only
Enrollment in non-calendar year policy ends	30 days	Date of event
Applicable to Marketplace (on-Exchange) Policies Only
Native American status	60 days	Eligible to enroll or change QHP policies on monthly basis
Attaining citizenship		Date of event
Demonstration of exceptional circumstances, as determined by the Exchange		Date of event

*Does not include loss of MEC due to failure to make premium payment and situations for allowable rescissions.

2015 Cost-Sharing Limits for ACA Compliant Plans

Below is from BCBS of Illinois. Note the link to the final rule. Also note that if the health insurance provider cannot meet the Medal requirements (for Bronze, Silver, Gold) with such a low deductible, then they are allowed to make it higher than the limit. This is what we are seeing in the market today.

From BCBS of Illinois

Legislative Update 
2015 Cost-Sharing Limits

The U.S. Department of Health and Human Services’ Notice of Benefit and Payment Parameters for 2015 final rule set the following cost-sharing parameters for 2015.

• Out-of-pocket Maximum: The maximum annual limit on cost sharing will be $6,600 for self-only coverage and$13,200 for family coverage. As a reminder, if a plan is non-grandfathered, out-of-pocket member expenses for in-network essential health benefits (EHBs) cannot exceed these out-of-pocket limits.

• Deductible Limit for Small Groups (1-50): The maximum annual limit on small group deductibles will be$2,050 for self-only coverage and $4,100 for family coverage. As a reminder, non-grandfathered small group plans must cap deductibles for in-network EHBs at these amounts.

• Pediatric Dental Coverage: Stand-alone pediatric dental plans covering pediatric dental EHBs will have cost-sharing limits of $350 for coverage of one child and $700 for coverage of two or more children.

This communication is intended for informational purposes only. It is not intended to provide, does not constitute, and cannot be relied upon as legal, tax or compliance advice. The information contained in this communication is subject to change based on future regulation and guidance.