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.

Individual Health Insurance Exchange (Marketplace) Subscribers and the 90 Day Grace Period to Pay Your Premium

Below is how BCBS of IL will handle claims for those people who have gotten a health insurance plan on the Exchange (Marketplace) AND receive a subsidy (Advance Premium Tax Credit).

It is my understanding that most other insurance carriers will be following a similar methodology, hence why I am posting this.

This is NOT for Small Group SHOP plans.

Blue Cross and Blue Shield of Illinois Providers Notified of ACA Grace Period Provision Providers will be receiving information in the Blue Cross and Blue Shield of Illinois (BCBSIL) provider newsletter about the Affordable Care Act (ACA) provision that allows Health Insurance Marketplace enrollees who receive the advance premium tax credit (APTC), a three-month grace period to pay their premium — provided they have already paid at least one month’s premium in full. It is important to note that not all members who purchase coverage on the Marketplace will receive the tax credit. During the three-month grace period, members are eligible for covered services under their plan.

The provision requires all payers to complete claims (for covered services rendered) in the first month of the grace period. For covered services rendered during months two and three, payers must either pay or hold claims for processing once the payments have been received. Notification of Eligibility Providers will be informed through eligibility and benefits verification when a member has entered into a grace period during months two and three of the grace period. All preauthorization letters will encourage providers to confirm whether the member is in a grace period prior to providing services. Claims Processing Payment for all allowable services provided during the first month of the grace period will be the responsibility of BCBSIL, subject to member cost sharing. During the second and third months of the grace period, BCBSIL will pend the claims the member incurs during this period. If the member pays all outstanding premium payment(s) in full, claims incurred during this period will process according to the member’s benefits. If the member has not paid premiums in full by the end of the grace period, BCBSIL will terminate the member’s policy retroactive to the first day of month two of the grace period. BCBSIL will deny any claims pended in months two and three of the grace period. Pharmacy Claims A member’s pharmacy claims will be denied during months two and three. If the member retroactively pays the premium in full, they may submit claims for prescriptions dispensed during this time to BCBSIL. If a member elects to receive a 90-day supply of a prescription during month one of the grace period, the member will receive the full 90-day prescription and BCBSIL will pay this claim. Member Responsibility for Payment We are encouraging providers to notify their patients that they will be responsible for payment of any outstanding claims for the full cost of provided services, if their health care coverage terminates at the end of the grace period.

Obama's "You Can Keep Your Plan" Announcement Isn't Up to Him

It's been awhile since I've posted due to trying to see every client I have along with renewing most of my groups with a December renewal date, but I thought I'd jump into the fray.

1. I've been amazed at how many times the Oval Office has made an announcement changing the law without due process. If a law is passed and someone wants to amend it, typically an amendment needs to be written and approved. This has not been the case with the Affordable Care Act (sorry, it's a beef of mine - I believe in following due process).

2. Now that the President has stated that insurance companies may be allowed to continue their plans up to the end of 2014, both the Directors of Insurance of each state AND the insurance companies within each state now need to make decisions.

3. The Director of Insurance (DoI) is the person who can decide whether to allow insurance companies to continue existing plans within that state. If the DoI chooses to disallow it, then it will be as if the President didn't make that announcement.

4. If the DoI says yes, the individual insurance companies can still say no. Insurance companies need to weigh the split in risk pools this may cause (or if they are pooling the risk pools, how the decrease in premium for existing plans will impact it). One of the reasons to force people onto the new plans is to get enough healthy people in the risk pool to pay for the unhealthy people. The whole risk model will change if this is the case and insurance companies need to carefully assess whether this makes sense. Furthermore, if insurance companies have already cancelled plans or people have chosen plans to migrate to, will the insurance companies be willing to go back and allow people to back on their old plans?

5. Let's say that insurance companies choose to continue existing plans. Policyholders should still see an increase in their premiums due to the new taxes that the Affordable Care Act has imposed. You have the $5.25/month belly button tax (transitional reinsurance fee paid for each person on a health insurance plan), person's portion of the health insurer tax (around 3% - 4% of the cost of the plan), and patient centered research outcome fee of $2/year. For a family of 4 whose current premium is $1000/month, this will mean the following extra costs: $21/month, $35/month (estimated at 3.5% health insurer fee), and $0.17/month pcori fee ($57.17/month total) assuming no other items included.

How to Navigate the Health Insurance Exchanges (Marketplace)

As we haven't been allow to see the steps involved with the Marketplace website (healthcare.gov, in Illinois you can also try getcoveredillinois.gov), here are some general ideas for you to be aware of.

1. You can go directly to each health insurer's website (that is in the Exchange) and look for health insurance both within the Exchange and outside of the Exchange.

2. You can go to healthcare.gov for any Federally Facilitated Marketplace or State/Federal Marketplace.

3. You will need an idea of what you think you will make in 2014. The rules state income is based upon Modified Adjusted Gross Income. They did not give details as to what that means, but for all practical purposes, think "Adjusted Gross Income." Estimate conservatively. If your income is much greater, then inform the Exchange to dial back your subsidy. The reason to do this is because the subsidies are actually forward looking tax credits. This means that the IRS will settle up with you at the end of the year. If the government has overpaid for your health insurance, they will ask for the money back! Of course if you had a bad year, the opposite is true too.

4. BE CAREFUL OF THE PLAN DESIGNS!!!!! I cannot stress this enough. The plans you will be viewing will be DIFFERENT that what you are used to.

• Some will include extremely high prescription drug deductibles (for example, you pay a $1500 drug deductible before the drug copay kicks in). 
• Others will include PER OCCURRENCE DEDUCTIBLES. Simply put, you pay this IN ADDITION to your normal deductible for things such as hospitalization, outpatient surgery, etc. An example would be you'd pay an extra $1000 each time you were admitted into a hospital, then you'd pay your deductible. 
• Silver level plans will have HIGH DEDUCTIBLES. Insurance companies did this to keep the costs down. You will need to choose between having a $4000+ individual deductible for a reasonable premium or a higher premium and lower deductible.
• THERE IS LESS CHOICE in the Exchange. If you do not qualify for a subsidy (you and your family make over 400% of Federal Poverty Level), then search for NON-EXCHANGE plans. In DuPage County, there are 3 insurance companies on the Exchange. Off-Exchange there are at least 5 with many more plans available. The rates for the same plan on and off the exchange will be exactly the same.
• PEDIATRIC DENTAL will be a question on the applications. If you say you do not have a dental plan, then they will charge you extra for including dental coverage for children. My best guess is that if you do not have children on the health insurance plan and don't have dental, you shouldn't be charged extra, but we won't know until tomorrow.
• IF YOU DON'T QUALIFY FOR A SUBSIDY consider getting a plan that starts 12/1/2013 with one of the insurance companies that will allow you to keep the plan for 1 full year. This will delay the increase in costs due to Health Reform for that much longer.
• PLEASE - USE AN AGENT!!! There is no cost to use an insurance agent certified to sell in the exchange. The rates are exactly the same and they will be able to help you avoid the pitfalls of choosing a plan that doesn't work for you. What you don't know WILL hurt you.

Please call me if you want help. My phone is 630-779-1144.

Thanks,

Robert Slayton

Why the Web Based Exchange is likely to blow up on Tuesday October 1st (A rant by Robert Slayton)

After spending weeks working with the Centers for Medicare and Medicaid Services (CMS.gov) to try to figure out whether I'm registered as an Agent on the Federally Facilitate Exchange, I had an epiphany of sorts. If they can't even get the training and registering part right for Insurance Agents, then how in the heck will they be able to get the web based Marketplace (Exchange) off the ground which will have tens of thousands more people trying to sign up for coverage?

Right now when you call CMS's help number for Insurance Agents, you receive a recording that the website has issues and that they are working on it. Ever since they opened up the website, (September 3rd), it hasn't worked correctly. When I talked to a CMS representative last week (30 minute wait, 15 minutes on the phone), they couldn't check my status or give me any information. They referred me to another website which just has general information. The worst part about that referral was the website had 98 characters (here it is: http://www.cms.gov/cciio/programs-and-initiatives/health-insurance-marketplaces/a-b-resources.html). Imaging trying to write down this website as they read it off to you.

Out of the hundreds of agents I track, only 2 have said they have gotten their FFM# (this allows them to write business within the exchange).

But wait, it gets better. Not only will you have no agents who can help until CMS resolves the registration issue, in Illinois, the Feds are saying rates and plans won't be released until October 1st, the very day the Marketplace opens.

How is ANYONE (Customer Service Reps working for the Exchange, Navigators, In Person Assisters, and Agents) going to be able to help people in the Marketplace if we don't have any time to review the plan designs and rates associated with the insurance before it goes live?

Maybe the government IS training their reps beforehand. Then they will be the ONLY ones who can answer questions on day 1, thereby increasing their call volume dramatically, thereby causing long wait times and unhappy customers.

Imagine if you ran a large corporation with thousands of sales people. Wouldn't you train them on the new product (plans available within the Marketplace) and give them pricing before launching? Doesn't this make sense? Apparently not for the Government.

In Politics, you can fudge a lot of things when it deals with people and paper. When it comes to technology, you can't fudge. Either it works or it doesn't work. Having worked for years for a technology company who has delivered "vaporware" to clients, I've been on the receiving end of the screaming and yelling when a product doesn't work.

It will be interesting to see whether the website works and can keep up with the traffic. If I were a betting person, I'd bet on the Exchange's portal not working smoothly the first day (and week).

Let's see whether my prognostication comes true. I sure hope not. . .

What if you build it and NOBODY comes? What happens if you offer health insurance coverage to your employees and only a few take it? Will you be penalized?

What if you build it and NOBODY comes? What happens if you offer health insurance coverage to your employees and only a few take it? Will you be penalized?

Many Large/Small employers are sweating whether insurance companies will allow them to have a plan if they don’t meet participation guidelines (roughly a minimum of 50% of employees must enroll for coverage or else the insurance company will NOT offer coverage – it’s more complex than that, but good enough this post).

The short answer is that if you are a small employer, the answer is YES you will be able to offer coverage without meeting participation guidelines, BUT open enrollment will ONLY be November 15 through December 15^th for a January 1^st start date. If you do meet the insurance company participation guidelines, you can have any renewal date you choose (just like it is now).

What about large employers who have less than 50 employees who want coverage? I have a client who has 268 full time employees, but only 16 will take the coverage. Will they be penalized? The answer is “we don’t know.” The National Association of Health Underwriters is working with HHS to come up with rules surrounding this occurrence.  My best guess is that there will be something just like what will happen for a small group (above).  Of course if you can be creative with “Standard Measurement Periods” and the “Look Back Period” you may be able to say to an insurance company that you only have 16 employees eligible for coverage. Most insurance companies at this point would consider the group a “small employer group” as they’d only recognize the 16 employees as full time eligible (and meet the participation guidelines).

Now let’s say that out of the 16 eligible, only 2 want the insurance (meaning you DON’T meet the guidelines). They would not be allowed to have the November 15^th – December 15^th open enrollment period because this special “Open Enrollment” period due to lack of participation would most likely be done only within the SHOP (small employer group health insurance) Exchange. 

As it is in the Exchange, the Government would not allow this particular group to shop in the exchange because, according to the ACA formula, they are a “large group employer.”  See the very last sentence of this blog post as to why I say this.

Companies with 50+employees who take coverage have more flexibility when it comes to getting insured. Some insurance carriers will say 20% participation (with a minimum of 50 taking coverage) is okay.

Ultimately, this is another thing that was unforeseen by the lawmakers which needs to be resolved.   

  

Below is text I took that describes the participation/open enrollment guidelines.

The following excerpt is from the Federal Register, Vol 78, No. 39/ Wednesday, February 27, 2013/ Rules and Regulations, page 13416. Here is a link from the state of Kentucky or you can google it yourself. http://healthbenefitexchange.ky.gov/Documents/Guaranteed%20Availability%20of%20Coverage.pdf

Comment: We received a few comments about the proposal that issuers would be allowed to decline to offer coverage to small employers for failure to satisfy minimum contribution or group participation requirements under state law or the SHOP standards.

Several commenters expressed support for the policy and recommended extending it to the large group market. One commenter emphasized that minimum participation and contribution standards must be reasonable and not burdensome to the point that small employers are discouraged from offering coverage.

Response: Upon further consideration of this issue, we have determined that small employers cannot be denied guaranteed availability of coverage for failure to satisfy minimum participation or contribution requirements.

As in the case of the bona fide association exception discussed above, while Congress left in place an exception for failure to meet contribution or participation requirements under the guaranteed renewability requirement in section 2703(b), it provided no such exception from the guaranteed availability requirement in section 2702.

To the contrary, language in the guaranteed availability provision for group health plans that was in place before the Affordable Care Act was not included in section 2702.

Accordingly, the proposed approach would conflict with the guaranteed availability provisions in section 2702 of the PHS Act. Moreover, permitting issuers to deny coverage altogether to a small employer with between 50 and 100 employees based on a failure to meet minimum participation or contribution requirements could subject such employer to a shared responsibility payment under section 4980H of the Code for a failure to offer coverage to its employees.

While section 2702 contains no exception to guaranteed availability based on a failure to meet contribution or minimum participation requirements, section 2702(b)(1) permits an issuer to limit enrollment in coverage to open and special enrollment periods.

Under our authority in section 2702(b)(3) to define ‘‘open enrollment periods,’’ we are providing in this final rule that, in the case of a small employer that fails to meet contribution or minimum participation requirements, an issuer may limit its offering of coverage to an annual open enrollment period, which we set forth in this final rule as the period beginning November 15 and extending through December 15 of each year.

As such, the group market will have continuous open enrollment, except for small employers that fail to meet contribution or minimum participation requirements, for which the enrollment period may be limited to the annual enrollment period described above, from November 15 through December 15. This approach addresses concerns about adverse selection in a manner that is consistent with the statutory provisions. We do not extend this provision to the large group market because large employers generally do not present the same adverse selection risk as small employers.

Affordable Care Act Open Enrollment FAQ for the Individual Market

Good stuff from BCBS of IL on when an individual can enroll in a health insurance plan.


May 29, 2013

Legislative Update
Affordable Care Act Question of the Week: Exchange Open Enrollment [All Markets]

We have received a number of questions about the initial open enrollment period for the Affordable Care Act (ACA). Beginning Jan. 1, 2014, most U.S. citizens and legal residents will be required to have a minimum level of health care coverage. If you have a general question about an ACA provision, contact your account representative.

Q: If an uninsured does not enroll through a health insurance exchange (also known as a health insurance marketplace) during the open enrollment period for coverage effective Jan. 1, 2014, under what circumstances may an individual enroll and receive coverage during 2014?

A: The initial open enrollment period for the exchange begins Oct. 1, 2013, and extends through March 31, 2014.

If an individual does not enroll during the initial open enrollment period or future enrollment periods (for plan years beginning on or after Jan. 1, 2015, the annual open enrollment period begins Oct. 15 and extends through Dec. 7 of the preceding calendar year), they can enroll if circumstances triggered one of the following events:

A qualified individual and any dependents losing other minimum essential coverage.
A qualified individual gaining or becoming a dependent through marriage, birth, adoption or placement for adoption.
An individual, not previously lawfully present, gaining status as a citizen, national or lawfully present individual in the United States.
A qualified individual experiencing an error in enrollment.
An individual enrolled in a Qualified Health Plan (QHP) adequately demonstrating to the exchange that the QHP in which he or she is enrolled substantially violated a material provision of its contract.
An individual becoming newly eligible or newly ineligible for advance payments of the premium tax credit or experiencing a change in eligibility for cost-sharing reductions.
New QHPs offered through the exchange becoming available to a qualified individual or enrollee as a result of a permanent move.
The individual is an Indian, as defined by the Indian Health Care Improvement Act. (We solicited comment on the potential implications on the process for verifying Indian status for purposes of this special enrollment period.)
A qualified individual or enrollee meeting other exceptional circumstances, as determined by the Exchange or Health & Human Services (HHS). Loss of coverage does not include failure to pay premiums on a timely basis, including COBRA premiums prior to expiration of COBRA coverage.
Unless specifically stated otherwise, an individual or enrollee has 60 days from the date of a triggering event to select a plan. Note: This 60-day Special Enrollment Period (SEP) window applies to the individual market. Group market is 30 days for the SEP window.

Obama Administration simplifies, significantly shortens application for health insurance

Obama Administration simplifies, significantly shortens application for health insurance

By Larry Grudzien, Attorney-At-Law

April 30, 2013

 

The Centers for Medicare & Medicaid Services (CMS) today announced that the application for health coverage has been simplified and significantly shortened. The application for individuals without health insurance has been reduced from twenty-one to three pages, and the application for families is reduce by two-thirds. The consumer friendly forms are much shorter than industry standards for health insurance applications today.

In addition, for the first time consumers will be able to fill out one simple application and see their entire range of health insurance options, including plans in the Health Insurance Marketplace, Medicaid, the Children's Health Insurance Program (CHIP) and tax credits that will help pay for premiums.

The applications released today, which can be submitted starting on October 1, can be found here:

http://cciio.cms.gov/resources/other/index.html#hie

"Consumers will have a simple, easy-to-understand way to apply for health coverage later this year," said CMS Acting Administrator Marilyn Tavenner. "The application for individuals is now three

The online version of the application will be a dynamic experience that shortens the application process based on individuals' responses. The paper application was simplified and tailored to meet personal situations based on important feedback from consumer groups.

Consumers can apply online, by phone or paper when open enrollment begins October 1, 2013. There will be clear information provided about how to complete the application, and how to access help applying and enrolling in coverage.

This consumer-focused approach will facilitate the enrollment of millions of Americans into affordable, high quality coverage while minimizing the administrative burden on states, individuals and health plans.

For more information about the Health Insurance Marketplace, visit: www.HealthCare.gov pages, making it easier to use and significantly shorter than industry standards. This is another step complete as we get ready for a consumer-friendly marketplace that will be open for business later this year."

For More Information:

If you have any comments or questions regarding any of above information, please do not hesitate to contact me at 630-779-1144 or Larry at (708) 717-9638.