How to Claim an SEP?

RayNY

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The time is here, starting next week, individual clients will need a "Qualifying Event" (QE) to generate a "Special Enrollment Period" (SEP) in order to enroll for coverage at any point between 4/1 and 11/15 when the next Open Enrollment starts.

We've already discussed what counts as a QE, but now for the more practical question, of "how the heck do I make use of an SEP?"

Healthcare.gov states "...In the Marketplace, you generally qualify for a special enrollment period of 60 days following a [Qualifying event]..." The full text of the law agrees: http://www.gpo.gov/fdsys/pkg/CFR-2013-title45-vol1/pdf/CFR-2013-title45-vol1-sec155-420.pdf

So, my client's sole-prop plan terms 6/1 (anniversary), no-fault loss of existing coverage is a QE. Moving to a new carrier and plan as an individual, small group coverage is no longer an option under the new rules.

"Following" that event, there are 60 days of SEP (6/1-8/1, or thereabout). So, starting 6/1 they are in an SEP and can apply. Under the same section of law, apps received between the 1st and 15th are effective the first day of the next month, or 7/1, producing a month lapse.

My exchange rep says they "think" you can request a term letter in advance from the carrier, and use that as proof of an SEP to apply. I informed her that receipt of a letter is not a QE, the contract termination is. She made it very clear she was guessing and can't promise it will work or be accepted. She also implied that the exchange wouldn't let you apply at all unless you can prove an SEP starting 4/1...

Anyone have a solid answer on how to make use of an SEP for an individual? Any guidance or procedures posted anywhere?
 
they have a whole week to figure it out and build the process/website............ give them a break. (facetiousness used in this post)
 
HHS is more reactive than proactive. I was hoping we could enroll the client before the qualifying event occurs.otherwise we will need to do short term medical to bridge the gap. In some cases it could open the client up to penalties. Oh my!
 
Allen, luckily, she won't face a penalty because the lapse is <3 months.
We *may* be able to enroll before the qualifying event occurs, but they can't "guarantee" it's possible (let alone, accepted by all those involved).

Presume STM isn't an option. Lets just say that a 30-day lapse will impose a significant financial burden if a major medical plan is not in place.
 
The time is here, starting next week, individual clients will need a "Qualifng Event" (QE) to roate a "Special Enrollment Period" (SEP) in order to enroll for coverage at any point between 4/1 and 11/15 when the next Open Enrollment starts.

We've already discussed what counts as a QE, but now for the more practical question, of "how the heck do I make use of an SEP?"

Healthcare.gov states "...In the Marketplace, you generally qualify for a special enrollment period of 60 days following a [Qualifying event]..." The full text of the law agrees: http://www.gpo.gov/fdsys/pkg/CFR-2013-title45-vol1/pdf/CFR-2013-title45-vol1-sec155-420.pdf

So, my client's sole-prop plan terms 6/1 (anniversary), no-fault loss of existing coverage is a QE. Moving to a new carrier and plan as an individual, small group coverage is no longer an option under the new rules.

"Following" that event, there are 60 days of SEP (6/1-8/1, or thereabout). So, starting 6/1 they are in an SEP and can apply. Under the same section of law, apps received between the 1st and 15th are effective the first day of the next month, or 7/1, producing a month lapse.

My exchange rep says they "think" you can request a term letter in advance from the carrier, and use that as proof of an SEP to apply. I informed her that receipt of a letter is not a QE, the contract termination is. She made it very clear she was guessing and can't promise it will work or be accepted. She also implied that the exchange wouldn't let you apply at all unless you can prove an SEP starting 4/1...

Anyone have a solid answer on how to make use of an SEP for an individual? Any guidance or procedures posted anywhere?



SEP questions were added to the subsidy app process back on 2/2/14 or thereabouts. I have generated plenty of SEP determinations on subsidy letters. Specifically, you should answer the "are you losing coverage in the next 60 days_” optional question as " yes" and enter the appropriate dates. You will get an SEP on the subsidy determination letter..

Its super easy...
 
SEP questions were added to the subsidy app process back on 2/2/14 or thereabouts. I have generated plenty of SEP determinations on subsidy letters. Specifically, you should answer the "are you losing coverage in the next 60 days_” optional question as " yes" and enter the appropriate dates. You will get an SEP on the subsidy determination letter..

Its super easy...

I've seen that Special Enrollment Period eligibility wording for my clients who owned plans that were terminating. The question in my mind (and my hope) is if those SEP qualifying questions will be asked up-front after this coming Monday 3/31/2014? If you can't answer "YES" to any of them, the system should advise you to come back when you can answer 'yes', or during the next Open Enrollment. Why go through all the other ID Verification, Family Composition and Income crap for nothing.

But, that probably makes too much sense to implement. After all, even private health insurers have traditionally asked the application-killer "Are You Pregnant?" at the end of the health questions section. The bozos who design application and qualification forms in private industry are (for the most part) lacking in common sense, so expecting HHS/CMS to demonstrate this trait it is a pipe-dream.
ac
 
Allen, luckily, she won't face a penalty because the lapse is <3 months.
We *may* be able to enroll before the qualifying event occurs, but they can't "guarantee" it's possible (let alone, accepted by all those involved).

Presume STM isn't an option. Lets just say that a 30-day lapse will impose a significant financial burden if a major medical plan is not in place.

HC.gov must have received many questions regarding enrollment when a current plan is about to terminate. Here's an updated Q&A relevant to this topic...

"Q: My current insurance plan expires in 2014, outside of the open enrollment period. Can I sign up for coverage at that time?

A: Yes. If you bought or renewed a plan in 2013 that ends in 2014, you’ll get a special enrollment period when that policy ends to buy new coverage for you and your family.

The special enrollment period begins 30 days before your plan ends in 2014. You have up to 60 days to enroll in coverage, either inside or outside of the Marketplace.

To avoid a gap in coverage, enroll in a new plan by the 15th of the last month of your current plan’s coverage."

Source: https://www.healthcare.gov/how-can-...eriod-can-i-sign-up-for-coverage-at-that-time (see bottom of page)

Does the bolded paragraph mean that your Special Enrollment Period window is available from 30 days before to 30 days after your existing health plan terminates?
ac
 
Post/Allen, thanks so much for your input.

This will be the first client going on post-Open Enrollment that I have been involved with. I now know what to look for in the application to generate an SEP, and what I must obtain from the current carrier as proof. You guys rock.

Allen, thanks for the additional guidance from HC.gov stating that in this particular situation, SEP begins 30 days prior to the expiration date. That would be a good thing for them to make more obvious (or have the exchange reps know!)

I'll report back once this has actually been done, and confirm the process.
 

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