So, what happens if you miss the ACA Open Enrollment that goes from November 1st through December 15th? You could end up with no coverage for the coming year. If you don’t sign up for health insurance during open enrollment, you may have to wait until November 2021 to sign up for a plan that will take effect in 2022. You may find that you can still get coverage for 2021, even after open enrollment ends. Let’s take a look.
Native Americans can enroll in exchange plans year-round.
People who qualify for Medicaid or CHIP can also enroll at any time. Income limits are fairly high for CHIP eligibility, so be sure you check your state’s eligibility limits before assuming that your kids wouldn’t be eligible – benefits very much extend to middle-class households.
If you’re on Medicaid and your income increases to a level that makes you ineligible for Medicaid, you’ll have an opportunity to switch to a private plan at that point, with the loss of your Medicaid plan serving as the qualifying event that triggers a special enrollment period.
A qualifying event at any time of the year will likely to allow you to enroll
Applicants who experience a qualifying event gain access to a special enrollment period (SEP) to shop for plans in the exchange (or off-exchange, in most cases) with premium subsidies available in the exchange for eligible enrollees.
HHS stepped up enforcement of special enrollment period eligibility verification in 2016 and further increased the eligibility verification process in 2017. So if you experience a qualifying event, be prepared to provide proof of it when you enroll.
And in most cases, the current rules limit SEP plan changes to plans at the same metal level the person already has. The state-run exchanges (ie, the ones that don’t use HealthCare.gov) can use their own discretion on this, but in general, if you’re enrolling mid-year, be prepared to provide proof of the qualifying event that triggered your special enrollment period, and know that you might not be able to switch to a more robust or less robust plan (eg, from bronze to gold or vice versa) during your SEP. And understand that in most — but not all — cases, the current SEP rules allow you to change your coverage but not necessarily go from being uninsured to insured. So you may be asked to provide proof of your prior coverage in addition to proof of the qualifying event.
For example, although a permanent move to an area where different health plans are available used to trigger a SEP regardless of whether you had coverage before the move, that’s no longer the case. You must have coverage in force before your move in order to qualify for a SEP in your new location. The same is true of getting married: In most cases, at least one spouse must have already had coverage in order for the marriage to trigger a SEP.
And without a qualifying event, major medical health insurance is not available outside of general open enrollment, on or off-exchange. This is very different from the pre-2014 individual health insurance market, where people could apply for coverage at any time. But of course, approval used to be contingent on health status, which is no longer the case.
If you’re curious about your eligibility for a special enrollment period, call (623) 889-7600 to discuss your situation with a licensed insurance professional.
The closest thing to ‘real’ insurance if you missed open enrollment
For people who didn’t enroll in coverage during the Open Enrollment, they aren’t eligible for employer-sponsored coverage or Medicaid/CHIP and aren’t expecting a qualifying event later in the year, the options for 2021 coverage are limited to policies that are not regulated by the ACA and are thus not considered minimum essential coverage.
And most of these plans are designed to be supplemental coverage, rather than a person’s only health coverage. This includes things like limited-benefit plans, accident supplements, critical/specific-illness policies, dental/vision plans, and medical discount plans.
But there are a few types of coverage that are available year-round (generally only to fairly healthy individuals), and that can serve as stand-alone coverage in a pinch:
Short Term Medical Plans
The application process is very simple for Short-Term Policies. Once you select a plan, the online application is much shorter than it is for standard individual health insurance, and coverage can be effective as early as the next day.
There are no income-related questions (since short-term policies are not eligible for any of the ACA’s premium subsidies), and the medical history section is generally quite short – nowhere near as onerous as the pre-2014 individual health insurance applications were.
Keep in mind that although the medical history section generally only addresses the most serious conditions in order to determine whether or not the applicant is eligible for coverage, short-term plans generally have blanket disclaimers stating that no pre-existing conditions are covered.
And post-claims underwriting is common on short-term plans. So although the insurer may accept your application based simply on what you disclose when you apply, they can — and likely will — go back through your medical history with a fine-toothed comb if and when you have a significant claim. If they find anything indicating that the current claim might be related to a pre-existing condition, they can rescind your coverage or deny the claim. So although a short-term plan might work well to cover a broken leg, it’s going to be less useful if you end up with a health condition that tends to take a while to develop, as the insurer may determine that the condition, or something related to it, began before your coverage was in force. This story is a good example of how this works.
Clearly, short-term plans are not as good as the ACA-regulated policies that you can purchase during open enrollment or during a special enrollment period. Short-Term Insurance is not regulated by the ACA, so it doesn’t have to follow the ACA’s rules: The plans still have benefit maximums, and they are not required to cover the ten essential benefits. (Most often, short-term plans don’t cover maternity, prescription drugs, preventive care, or mental health/addiction treatment), they do not have to limit out-of-pocket maximums, and they do not cover pre-existing conditions. They also still use medical underwriting, so coverage is not guaranteed.
The majority of short-term plans do not cover outpatient prescriptions. Using a pharmacy discount card may lower medication costs without health insurance, and some discount prices may be lower than an insurance copay. Losing Short Term Medical coverage is not a qualifying event to trigger a Special Enrollment Period.
If you would like to discuss ACA Enrollment, Short Term Plans, or have other questions or concerns regarding Health Insurance in Arizona, please give Group Plans Inc a call at (623) 889-7600.