What is a Qualifying Event and What Should I Do if I Have One?

Note: this post was originally published on May 12, 2014 but has been updated for 2015.

When it comes to health insurance, a qualifying event is a life event that makes you eligible to purchase health insurance outside the dates of open enrollment.  A qualifying event triggers a special enrollment period lasting 30-60 days, depending on the event.  Read more about special enrollment periods.

Examples of Qualifying Events

• Change in marital status (marriage/divorce/death of a spouse)

• Relocation to a new state or to an area of your current state where the plans offered are different

• Change in family size (birth/adoption/death of a child)

• Involuntary loss of minimum essential health coverage (change in employment status, cancellation of current coverage)

• Certain changes in income

• Expiration of COBRA benefits

Newly added by the Department of Health and Human Services (HHS) and effective April, 2015:

• A change in family structure — for example becoming a dependent or gaining a dependent through birth, adoption, or placement in foster care — which causes your current plan to no longer meet your needs. You could switch, for example, from single to family coverage during a special enrollment period. HHS is not mandating this change until 2017, but is encouraging exchanges to offer it as soon as possible.

• An increase in your income to the federal poverty level (FPL) if you live in a state which has not expanded Medicaid. Earning at least 100% of FPL takes you out of the Medicaid coverage gap and makes you eligible for premium tax credits when buying health insurance on the exchange.

• If a court order requires someone to provide health insurance (for example during divorce proceedings), the coverage must be available the first day the court order takes effect, even if that date is outside open enrollment.

• If you have a pre-Affordable Care Act plan which does not run on a calendar year basis, and that coverage terminates outside the dates of open enrollment.

What Should You Do if You Have a Qualifying Event?

If you do have a qualifying event, you must have proof of the event in order to be eligible to purchase a new plan.  When applying for coverage, you will need to submit verification of the event and the date it occurred. Without verification, most carriers will not process the application.

If you have a qualifying event and you are eligible for a subsidy (click here to find out), then you will need to purchase coverage on your state’s health insurance exchange (healthcare.gov for Virginia residents, marylandhealthconnection.com for Maryland residents, dchealthlink.com for DC residents).

If you are not eligible for a subsidy, you can apply directly with the carrier of your choice:

• CareFirst BC/BS
• Anthem BC/BS
• Kaiser Permanente
• Humana
• UnitedHealth Care
• Assurant Health
• Innovation Health/Aetna

But remember, you have a limited amount of time after a qualifying event to purchase new coverage, so you must act quickly.

Give our office a call at 703-707-8270 and we’d be glad to help.

Buying 2015 Health Insurance Outside of Open Enrollment

A qualifying event opens the door to purchase coverage outside of open enrollment.

Open enrollment for 2015 health insurance has ended.  It ran from November 15, 2014 through February 15, 2015.

Outside those dates, you must have a qualifying event in order to be eligible to purchase Affordable Care Act-compliant coverage which is effective in 2015.

NOTE: Anthem has extended its deadline to purchase off-exchange 2015 coverage until February 28.  Click here for more info.

Examples of Qualifying Events

• Change in marital status (marriage/divorce/death of a spouse)
• Relocation to a new state
• Change in family size (birth/adoption/death of a child)
• Loss of minimum essential health coverage (change in employment status, cancellation of current coverage)
• Certain changes in income
• Expiration of COBRA

Qualifying Events Trigger a Special Enrollment Period

A qualifying event triggers a special enrollment period during which you can enroll in a health insurance plan outside of open enrollment.

Most special enrollment periods last 60 days, so be sure to act quickly if you have one of these events.

If You Have a Qualifying Event

If you do have a qualifying event, you must have proof of the event.  When applying for coverage, you will be asked to submit verification of the event and the date it occurred. Without verification, most carriers will not process the application.

If you have a qualifying event and you are eligible for a subsidy (click here to find out), then you must purchase coverage on your state’s health insurance exchange in order to collect the subsidy (healthcare.gov for Virginia residents, marylandhealthconnection.com for Maryland residents, dchealthlink.com for DC residents).

If you are not eligible for a subsidy, you can apply directly with the carrier of your choice:

• CareFirst BC/BS
• Anthem BC/BS
• Kaiser Permanente
• Humana
• UnitedHealth Care
• Assurant Health
• Innovation Health/Aetna

What if You Don’t Have a Qualifying Event?

Absent a qualifying event, most individuals will not be able to purchase Affordable Care Act (ACA)-compliant health insurance coverage for 2015 after February 15*.  Instead, you will need to wait until next year’s open enrollment to buy coverage effective in 2016.

If you are concerned about being uninsured for the remainder of 2015, you may have an option to purchase a temporary policy as a bridge through the end of the year.

Temporary plans offered outside of a special or open enrollment period will not be ACA-compliant.  One critical missing piece will be coverage for pre-existing conditions; they will not be covered.  But you would be covered for any new illness or injury that arises.  Although not ideal, a temporary plan is better than having no coverage at all.

Here are two companies we work with that offer short term, temporary coverage:

• Assurant Health
• UnitedHealth Care

Virginia Medical Plans Can Help

If you have a qualifying event, let us know right away so we can help you find new coverage that will best meet your needs.

Even without a qualifying event, if you do not have health insurance, give us a call.  We may be able to help you at least find a temporary policy to give you peace of mind until 2016.

Give us a call at 703-707-8270.

*Exception — Anthem BC/BS has extended its deadline to purchase off-exchange 2015 plans to February 28, 2015.  Click here for more information.

If I Currently Have COBRA Can I Switch to a Marketplace Plan?

COBRA, which is known by most as continuation of benefits, stands for the Consolidated Ominbus Reconciliation Act.  Under this 1985 law, covered employees and their dependents who lose health insurance because of one of a series of qualifying events* are entitled to purchase continuation of that coverage.  COBRA however, is typically very expensive.

Now that the Affordable Care Act (ACA) is here, many people who qualify for COBRA can find more affordable coverage by buying a plan on the marketplace (aka the exchange) with financial assistance in the form of a premium subsidy and/or reduction of cost sharing.  Click here to see if you may qualify for assistance.

An event* that would make you eligible to start COBRA would also make you eligible to purchase coverage on the exchange during a special enrollment period.

But What if You Already Have COBRA?  Can You Switch to a Marketplace Plan to Save Money?

The answer depends on when and why your existing COBRA coverage is ending.

Prior to July 1, 2014 in States Using the Federal Marketplace (eg., Virginia)

For a limited time, you may be able to enroll in a new plan through the federal marketplace, regardless of the reason you are ending your COBRA coverage.

This is because of a special enrollment period created by the Department of Health and Human Services (HHS) to address concerns that employees may not have been given enough information about marketplace plans to fully understand their options.  Click here to read the HHS notice.  You must call the Marketplace Call Center at 1-800-318-2596 to get approval for this special enrollment period.  The extension goes through July 1, 2014.

During Open Enrollment

During an open enrollment period you can drop your COBRA coverage for any reason and instead purchase a marketplace plan.

Note: Open enrollment for 2014 coverage ended on March 31, 2014.  Open enrollment for 2015 coverage is November 15, 2014 through February 15, 2015.

Outside of Open Enrollment

Things get a little trickier if you are ending your COBRA coverage outside the dates of regular open enrollment (unless it during the special enrollment period of May 2, 2014 through July 1, 2014 mentioned above).

If you wish to end your COBRA benefits early, you cannot enroll in a marketplace plan outside of open enrollment.  You must wait until either the next open enrollment period or until your COBRA coverage runs out on its own.

If your coverage runs out, this qualifies you for a 60-day special enrollment period during which you can enroll in a marketplace plan.

Avoid a Gap in Coverage

If you are going to replace your COBRA coverage with a marketplace plan, make sure you don’t have a gap in coverage by keeping your COBRA in effect until your new plan starts.

Keep in mind that If you apply for coverage between the 1st and 15th of a month, your coverage will be effective on the 1st of the very next month.  If you enroll between the 16th and last day of the month, your coverage will begin on the 1st of the second next month.  (For example if you enroll between January 1 and 15, coverage begins February 1; if you enroll between January 16 and 31, coverage begins March 1).

Contact Virginia Medical Plans for Help

Virginia Medical Plans can help you select and purchase a marketplace plan.  Simply enter our broker information when applying online through healthcare.gov:

First name: Jonathan
Last name: Katz
FFM User ID: JONKATZAGENT
NPN Number: 1585616

Contact us today if you need help choosing a plan on or off of the marketplace.

*Qualifying events for COBRA include termination of employment, reduction of hours, divorce or legal separation, death, eligibility for Medicare, loss of dependent child status.  Click here for a more detailed look at qualifying events.

What is a Qualifying Event and What Should I Do if I Have One?

Note: this post was originally published on May 12, 2014 but has been updated for 2015. What appears here is the updated information, as of March 2015.

When it comes to health insurance, a qualifying event is a life event that makes you eligible to purchase health insurance outside the dates of open enrollment.  A qualifying event triggers a special enrollment period lasting 30-60 days, depending on the event.  Read more about special enrollment periods.

Examples of Qualifying Events

• Change in marital status (marriage/divorce/death of a spouse)

• Relocation to a new state or to an area of your current state where the plans offered are different

• Change in family size (birth/adoption/death of a child)

• Involuntary loss of minimum essential health coverage (change in employment status, cancellation of current coverage)

• Certain changes in income

• Expiration of COBRA benefits

Newly added by the Department of Health and Human Services (HHS) and effective April, 2015:

• A change in family structure — for example becoming a dependent or gaining a dependent through birth, adoption, or placement in foster care — which causes your current plan to no longer meet your needs. You could switch, for example, from single to family coverage during a special enrollment period. HHS is not mandating this change until 2017, but is encouraging exchanges to offer it as soon as possible.

• An increase in your income to the federal poverty level (FPL) if you live in a state which has not expanded Medicaid. Earning at least 100% of FPL takes you out of the Medicaid coverage gap and makes you eligible for premium tax credits when buying health insurance on the exchange.

• If a court order requires someone to provide health insurance (for example during divorce proceedings), the coverage must be available the first day the court order takes effect, even if that date is outside open enrollment.

• If you have a pre-Affordable Care Act plan which does not run on a calendar year basis, and that coverage terminates outside the dates of open enrollment.

What Should You Do if You Have a Qualifying Event?

If you do have a qualifying event, you must have proof of the event in order to be eligible to purchase a new plan.  When applying for coverage, you will need to submit verification of the event and the date it occurred. Without verification, most carriers will not process the application.

If you have a qualifying event and you are eligible for a subsidy (click here to find out), then you will need to purchase coverage on your state’s health insurance exchange (healthcare.gov for Virginia residents, marylandhealthconnection.com for Maryland residents, dchealthlink.com for DC residents).

If you are not eligible for a subsidy, you can apply directly with the carrier of your choice:

• CareFirst BC/BS
• Anthem BC/BS
• Kaiser Permanente
• Humana
• UnitedHealth Care
• Assurant Health
• Innovation Health/Aetna

But remember, you have a limited amount of time after a qualifying event to purchase new coverage, so you must act quickly.

Give our office a call at 703-707-8270 and we’d be glad to help.