IMPORTANT: Many will qualify for a SEP whether HC.gov announces one for #COVID19 or not.
No one has been shouting from the rooftops louder than I have for HHS Secretary Alex Azar or CMS Administrator Seema Verma to join nearly all of the state-based ACA exchanges in announcing an official Special Enrollment Period (SEP) in light of the ongoing Coronavirus pandemic, and I'm still urging them to do so as soon as possible. The federal ACA exchange, HealthCare.Gov, hosts ACA enrollment for 38 states representing around 75% of the national population, so this is a pretty big deal.
Having said that, it's important to keep in mind that even without a COVID-19-specific SEP, many people already qualify to enroll in ACA-compliant healthcare coverage anyway, whether they're currently uninsured or because they're about to be...or because their personal circumstances are about to change. And none of these have anything to do with the COVID-19 crisis, although it's certainly going to cause a whole lot more people to qualify for two of those changes:
Special Enrollment Period (SEP)
A time outside the yearly Open Enrollment Period when you can sign up for health insurance. You qualify for a Special Enrollment Period if you’ve had certain life events, including losing health coverage, moving, getting married, having a baby, or adopting a child.
Depending on your Special Enrollment Period type, you may have 60 days before or 60 days following the event to enroll in a plan. If you miss your Special Enrollment Period window, you may have to wait until the next Open Enrollment Period to apply.
You can enroll in Medicaid or the Children’s Health Insurance Program (CHIP) any time of year, whether you qualify for a Special Enrollment Period or not.
Here's the official list of Qualifying Life Events which make you eligible for a Special Enrollment Period regardless of which state you live in:
Life changes that can qualify you for a Special Enrollment Period
Changes in household
You may qualify for a Special Enrollment Period if you or anyone in your household in the past 60 days:
- Got married. Pick a plan by the last day of the month and your coverage can start the first day of the next month.
- Had a baby, adopted a child, or placed a child for foster care. Your coverage can start the day of the event — even if you enroll in the plan up to 60 days afterward.
- Got divorced or legally separated and lost health insurance. Note: Divorce or legal separation without losing coverage doesn’t qualify you for a Special Enrollment Period.
- Died. You’ll be eligible for a Special Enrollment Period if someone on your Marketplace plan dies and as a result you’re no longer eligible for your current health plan.
Changes in residence
Household moves that qualify you for a Special Enrollment Period:
- Moving to a new home in a new ZIP code or county
- Moving to the U.S. from a foreign country or United States territory
- If you're a student, moving to or from the place you attend school
- If you're a seasonal worker, moving to or from the place you both live and work
- Moving to or from a shelter or other transitional housing
Note: Moving only for medical treatment or staying somewhere for vacation doesn’t qualify you for a Special Enrollment Period.
Important: You must confirm you had qualifying health coverage for one or more days during the 60 days before your move. You don't need to provide confirmation if you’re moving from a foreign country or U.S. territory.
Loss of health insurance
You may qualify for a Special Enrollment Period if you or anyone in your household lost qualifying health coverage in the past 60 days OR expects to lose coverage in the next 60 days.
Coverage losses that may qualify you for a Special Enrollment Period:
- Losing job-based coverage
- Losing individual health coverage for a plan or policy you bought yourself
- Losing eligibility for Medicaid or CHIP
- Losing eligibility for Medicare
- Losing coverage through a family member
NOTE: "Losing coverage through a family member" includes adult children who are dropped from their parents plan when they turn 26.
An employer offer to help with the cost of coverage
You may qualify for a Special Enrollment Period if you or anyone in your household newly gained access to an individual coverage HRA or a Qualified Small Employer Health Reimbursement Arrangement (QSEHRA) in the past 60 days OR expects to in the next 60 days.
Note: Your employer may refer to an individual coverage HRA by a different name, like the acronym “ICHRA.”
Generally, you’ll need to apply for and enroll in individual health insurance before your individual coverage HRA or QSEHRA starts. However, your employer may offer different options for when your individual coverage HRA or QSEHRA can start so you have more time to enroll. Contact them or check the notice you got from your employer for more information. If you’re currently enrolled in a Marketplace plan with savings, these savings may change because of the help you get through a job. Get more information on how your savings may change if you have an individual coverage HRA or QSEHRA offer.
If you qualify to enroll in Marketplace coverage through this Special Enrollment Period, call the Marketplace Call Center to complete your enrollment. You can’t do this online.
More qualifying changes
Other life circumstances that may qualify you for a Special Enrollment Period:
- Gaining membership in a federally recognized tribe or status as an Alaska Native Claims Settlement Act (ANCSA) Corporation shareholder
- Becoming newly eligible for Marketplace coverage because you became a U.S. citizen
- Leaving incarceration
- Starting or ending service as an AmeriCorps State and National, VISTA, or NCCC member
In addition to the list above, there are additional Qualifying Events which make residents eligible for an SEP in certain states as well. For instance:
- In a few states, becoming/being pregnant is a qualifying event
- In New York (and possibly via HealthCare.Gov?), victims of domestic violence qualify for an SEP
- In Colorado, they recently offered a SEP for victims of the Trinity Healthshare scam, although that ended a few days ago
...and so forth. The state-specific SEPs are pretty much confined to the 13 full State-based Exchanges (set to become 16 this November as Pennsylvania, New Jersey and New Mexico are preparing to split off of HC.gov as well).
Even under normal circumstances, historically, nationally, around 8,000 people enroll in ACA coverage during the off-season via SEPs each and every day (while a slightly higher number typically drop ACA exchange coverage daily due to similar life changes...that is, for every young adult turning 26 and enrolling in exchange coverage, there's another older adult turning 65 and moving off of exchange coverage in favor of Medicare; for every newly-divorced person enrolling for their own coverage there's a newly-married person dropping exchange coverage in favor of their spouse's employer plan, and so forth).
Most of the list above won't change much during the COVID-19 crisis, but a lot more people are (sadly) very likely to become eligible for one of them in particular:
- Losing job-based coverage
As hundreds of thousands...or potentially even millions of people...lose their jobs over the next few months, they're going to also lose their employer-sponsored healthcare coverage. While many of them will have the option of keeping that coverage for awhile via COBRA, they'd have to start paying full price if they do so, and the income loss is going to make that an impossible option in many cases.
As long as their income for the balance of 2020 and into 2021 is below 400% of the Federal Poverty Level (which in most cases it would be, given that they just lost their jobs), they'll likely qualify for ACA premium subsidies and many will also qualify for Cost Sharing Reduction CSR) assistance. Of course, if their income really drops substantially to below the 138% FPL threshold, in most states the'll also qualify for Medicaid, while their children will often qualify for CHIP.
And remember, if you're eligible for the programs, you can enroll in Medicaid or CHIP anytime throughout the year without requiring an SEP. This also holds true for the MinnesotaCare program in Minnesota, the Essential Plan program in New York State and ConnectorCare plans in Massachusetts.
Having said all of this, it's still important for HealthCare.Gov, Your Health Idaho, MNsure and Vermont Health Connect to launch a formal COVID-19 SEP as well.