The Universal SEP

[RayNY]

York,

45 CFR 155.420 - Special enrollment periods. | LII / Legal Information Institute Full text of the SEP rule, it's worth the read as it seems you have questions on it. Dates are well defined in there.

For birth, plan is effective the day of birth. (Section (b)(2)(i))

I'm almost positive that an SEP applies to a "coverage household", which was defined by my exchange to mean "everyone who can go on a single contract". Multiple carriers and my exchange have confirmed and reiterated this. If anyone in the "coverage household" has an SEP, everyone is eligible to utilize it.

I know we've debated the "change coverage" vs "obtain new coverage" question when it comes to SEP's, and while we can still debate the legalese, the reality is, the exchange is letting you obtain new coverage.

 

[Ann H]

Great thread, I am getting conflicting reports from HC.gov about others in H/H qualifying when there is a new dependent, under the newborn/adoption rule. I don't want to lead the parent to believe that with no prior coverage now they can get their own coverage outside of open enrollment. The recent one I did, there was end of group coverage involved, too, as I recall. So that one was not a no prior coverage situation.
Also, if there is a SEP for the new parent with no prior coverage, would the effective date be the date of birth/adoption or 1st of next month, if parent enrolled within the 60 days? Anyone had this situation? I know we could just do an app, and I could reach out to a parent in this situation before the end of the 60 days. I would rather have a good idea of their eligibility chances before taking up their time. It's also close to open enrollment.
When I ask these questions at HC.gov, I get different answers. One did say they had done some apps and only the child got the SEP. Others weren't so sure.

This is really a timely question. I have one of those on my desk right now. I reached out to some friends for help, and TaterPeeler and AllenChicago really stepped up to the plate and gave me the detailed answers.

For a newborn, a "date of birth effective date" is available. Birth creates an SEP for the whole family, if they want it, just like RayNY said above.

Below is the text in the actual regulation, and I'm sending out another big THANK-YOU to TaterPeeler and AllenChicago for pointing me to this.

(2) Special effective dates. (i) In the case of birth, adoption, placement for adoption, or placement in foster care as described in paragraph (d)(2) of this section, the Exchange must ensure that coverage is effective for a qualified individual or enrollee on the date of birth, adoption, placement for adoption, or placement in foster care, or it may permit the qualified individual or enrollee to elect a coverage effective date of the first day of the month following the date of birth, adoption, placement for adoption, or placement in foster care. If the Exchange permits the qualified individual or enrollee to elect a coverage effective date of the first day of the month following the date of birth, adoption, placement for adoption, or placement in foster care, the Exchange must ensure coverage is effective on such date elected by the qualified individual or enrollee.​

eCFR — Code of Federal Regulations - that's the official website. Just put "birth" in the browser's search box and it will show you the correct section. Some of my local carriers were saying it must be "first of the month following" date of birth because the parents (in my client's case) were NOT already insured under an IFP plan. But this reg says otherwise, and some of the carriers already knew that.

 

[yorkriver1]

Great info, thanks! So kind of like COBRA, where you can wait a couple months (60 days for ACA SEP) to elect coverage, but if you do wait, you will still owe money back to the required/requested 1st of following month after the birth/adoption date. The up and downside, depending on the situation.

 

[RayNY]

York,

That's right on. I will say, unofficially, that the exchange may provide concessions to clients that do not comply strictly with the law, like allowing a one month lapse instead of the plan being effective the 1st day. The law clearly defines the effective date, but I personally put 2 separate clients through with one month lapses (after speaking with an exchange rep and requesting it directly). If your client wants something, it might be worth the call into the exchange to see if they'll allow it.

 

[yorkriver1]

Thanks, Ray! Lately I have been getting the comment from HC.gov reps more than once, that if we need some kind of tweak to an app done on line to call them. The reps can make corrections in the app on their end. Your description of asking for a later date in LOC cases where backdating is the norm is exactly what I can now look into.
I will eventually get over this: Most reps finally understand that loss of coverage effective dates have no 1 month delay when the client applies at the end of the month, but within 60 days. They forced one of my clients earlier this year to wait a month and all swore it was valid. Client waited to almost the end of the 60 days, then had to wait a gap month because he applied after the 15th. Client was turned down online due to something about how a question was answered that was fixed. The rep then set up the coverage effective date one month out. No amount of Yosemite Sam on my part was working, had to move on. All turned out OK, but, still...

 

[AllenChicago]

November 9, 2014

Hypothetical Case: Thomas loses coverage on November 30, 2014. This triggers a 60 day Special Enrollment Period. He will purchase coverage (either on, or off exchange) on January 30, 2015. The software will automatically make his coverage effective retroactively.. back to December 1, 2014.

Question: Will Thomas be enrolled in a 2014 plan, or a 2015 plan?

Hunch: The system might just seize up and not allow Thomas to enroll at all!

ac

 

[houcoogster]

November 9, 2014

Hypothetical Case: Thomas loses coverage on November 30, 2014. This triggers a 60 day Special Enrollment Period. He will purchase coverage (either on, or off exchange) on January 30, 2015. The software will automatically make his coverage effective retroactively.. back to December 1, 2014.

Question: Will Thomas be enrolled in a 2014 plan, or a 2015 plan?

Hunch: The system might just seize up and not allow Thomas to enroll at all!

ac

He will be enrolled in a 2014 plan for one month then auto enrolled in the 2015 version of the same.

 

[Ann H]

So, I suppose this is a stupid question, but please have patience with me since I do mostly OFF exchange business.

On October 30th and 31st, I had 3 SEPs to enroll, all of whom called me last minute to say they were losing health insurance at the end of October. The hc.gov website was down for maintenance. I called the 1-800 number, and the reps could take an app manually, but they couldn't enter it into the website because it was down. The reps told me I lost out on an 11/1 effective date (and didn't seem to understand the gravity of that situation!) So, if I go back to hc.gov now, and enter a 10/31/2014 date of loss of coverage, will it give us the 11/1/2014 insurance effective date anyway? Or will they get a 12/1/2014 effective date?

 

[FLM2]

So, I suppose this is a stupid question, but please have patience with me since I do mostly OFF exchange business.

On October 30th and 31st, I had 3 SEPs to enroll, all of whom called me last minute to say they were losing health insurance at the end of October. The hc.gov website was down for maintenance. I called the 1-800 number, and the reps could take an app manually, but they couldn't enter it into the website because it was down. The reps told me I lost out on an 11/1 effective date (and didn't seem to understand the gravity of that situation!) So, if I go back to hc.gov now, and enter a 10/31/2014 date of loss of coverage, will it give us the 11/1/2014 insurance effective date anyway? Or will they get a 12/1/2014 effective date?

Ann, the answers are either (1) probably (2) very likely or (3) call 1-800-POTUS14

The real answer, I believe, is that once you enroll in a plan under a SEP that is the only election you can make-it might be possible to update the application information with the 10/31 loss of coverage and change the effective date but let's face it, there are no hard and fast rules to any of this, it's just whatever someone decides at the moment the application is placed.

 

[AllenChicago]

On October 30th and 31st, I had 3 SEPs to enroll, all of whom called me last minute to say they were losing health insurance at the end of October. So, if I go back to hc.gov now, and enter a 10/31/2014 date of loss of coverage, will it give us the 11/1/2014 insurance effective date anyway? Or will they get a 12/1/2014 effective date?

So far this year, on-Exchange SEP applications have auto back-dated to the 1st of the month after the month in which the coverage was lost. Off-Exchange have behaved the same way.

This "rule" caused me much grief with one client who HAD to pay 60 days premiums in arrears. Took 6 weeks of calls/letters to get this changed to the 1st of the month in which the enrollment took place, which is what she wanted.
ac