ACA News & Publications

ACA Pathways: Special Enrollment Events For Marketplace Coverage

June 10, 2014

Under the Affordable Care Act (ACA), individuals that need health coverage who want to enroll in a health plan offered through Covered California (CoveredCA), California's health care marketplace, generally must do so during CoveredCA's annual open enrollment period. For 2014 coverage, the open enrollment period ended on March 31, 2014. The 2015 open enrollment period will not begin until November 15, 2014 (and will run through February 15, 2015).

However, individuals still have several opportunities to enroll prior to the 2015 open enrollment period. These are known as special enrollment, or qualifying life events, and are described further below. To enroll, individuals must report changes and select a CoveredCA plan within 60 days of the qualifying life event to purchase a CoveredCA health insurance plan outside of open enrollment.

In addition, individuals who qualify for Medi-Cal may enroll at any time of the year, as can members of a federally recognized American Indian tribe and Alaska natives, who also are permitted to change plans monthly. No qualifying life event or special enrollment period is required.

One-time Special Enrollment Event for COBRA Participants

Individuals who are eligible for, or currently enrolled in, COBRA coverage, have until July 15, 2014 to take advantage of a one-time special enrollment opportunity to enroll in a CoveredCA health insurance plan option in lieu of their COBRA coverage.

Qualifying Life Events

  1. Involuntary coverage changes, including any of the following:
    • Loss of Medi-Cal coverage.
    • Loss of employer-sponsored coverage.
    • Exhaustion of COBRA coverage (Note: Failure to pay COBRA premiums is not considered a loss of coverage).
    • Loss of eligibility for student health coverage.
    • Loss of eligibility for coverage on a parent's health plan due to attainment of age 26.
    • Loss of coverage on a child-only plan as a result of turning age 19.
  2. A permanent move to/within California. This qualifying event applies to individuals who move to California from out of state and who gain access to at least one new CoveredCA health plan option.
  3. Birth, adoption, or receipt of a child into foster care. The entire family can use the special enrollment period to enroll in coverage. In addition, if an individual places a child for adoption or foster care, the individual can use a special enrollment period to enroll in coverage.
  4. Marriage or entering into domestic partnership. One or both members of the new couple can use the special enrollment period to enroll in CoveredCA for coverage.
  5. A return from active duty military service, for individuals who may have lost coverage after leaving active duty, reserve duty, or the California National Guard.
  6. Release from jail or prison.
  7. Attaining U.S. citizenship, becoming a U.S. national, or attaining permanent legal residency status.
  8. For, individuals currently enrolled in CoveredCA , a change in income or household status that affects eligibility for premium tax credits or cost-sharing reduction.
  9. Becoming eligible for COBRA coverage due to the loss of employer-sponsored insurance.
  10. Misconduct or misinformation occurring during the CoveredCA open enrollment process. Examples include the following situations:
    • If an agent, enrollment counselor, Service Center representative or other authorized representative either enrolled the individual in a plan that the individual did not want to be enroll in, failed to enroll the individual in a CoveredCA plan, or failed to calculate premium assistance for which the individual was eligible.
    • An incorrect eligibility determination was made during open enrollment. For example, if an individual was initially informed he or she was eligible for Medi-Cal and then was later determined not to be eligible.
    • The individual's information was not received by the health plan due to technical issues.
    • There were errors in the processing of immigration documents that resulted in an incorrect eligibility determination.
    • Incorrect plan data was displayed on the website when a health plan was selected, such as data errors on premiums, benefits or copay/deductibles; incorrect plans; or situations whereby a family could not enroll together in a single plan.
  11. Violation of contract by the individual's health plan.
  12. Exceptional circumstances occurring on or around plan selection deadlines, including natural disasters and medical emergencies.
  13. Loss of eligibility for a hardship exemption outside of CoveredCA's open enrollment period.
  14. Receipt of a court order to provide health insurance for a child who was determined to be ineligible for Medi-Cal or a Children's Health Insurance Program, even though the individual is not the party who expects to claim the child as a tax dependent.
  15. Beginning or ending service in AmeriCorps, VISTA, or National Civilian Community Corps, outside of the CoveredCA open enrollment period.
  16. Participants currently in a "grandfathered" health insurance plan outside of CoveredCA, opting to switch to a CoveredCA plan instead of renewing current coverage under the grandfathered plan.
  17. Provider leaving the health plan network while the individual was receiving care for either of the following conditions: (i) pregnancy, (ii) terminal illness, (iii) an acute or serious chronic condition, (iv) the care of a newborn child between birth and age 36 months, or (v) a surgery or other procedure that will occur within 180 days of the termination or start date.
  18. Certain one-time special enrollment events (2014 only):
    • Participants in the Pre-existing Condition Insurance Program (PCIP) have until June 30, 2014 to enroll in a CoveredCA plan. Under this limited-time special enrollment period, eligible individuals are entitled to retroactive coverage beginning on May 1, 2014 (Note that PCIP participants that qualify for Medi-Cal may enroll at any point during the year). Please contact the CoveredCA Service Center for further information.
    • Victims of domestic abuse had until May 31, 2014, to enroll for coverage in a CoveredCA plan.

If none of the above qualifying life events apply, individuals are still encouraged to apply for coverage into CoveredCA by indicating "None of the above," on the application, as the individual may be eligible for Medi-Cal or California's Access for Infants and Mothers (AIM) program for pregnant women based on the individual's income. Regardless of which qualifying life event applies, the application will still be reviewed for coverage through Medi-Cal and AIM.

Special Enrollment Opportunities- Federally-Facilitated and Other State Marketplaces

Similar special open enrollment opportunities are available for individuals residing in states other than California, including those with federally-facilitated marketplaces.

Those in states with federally-facilitated marketplaces who currently have COBRA coverage and want to instead enroll in a marketplace health plan may do so through July 1, 2014 (versus the July 15, 2014 deadline permitted by CoveredCA). Individuals wishing to take advantage of this special enrollment period, contact the marketplace call center at 1-800-318-2596 in order to start the application process.

Individuals residing in states that have established their own marketplace, should access their respective marketplace website or contact their respective marketplace call center, for further information.

For More Information
For more information about this ACA Pathways or about any other health care reform-related provisions, please contact your Burnham Benefits consultant or Burnham Benefits at:

Burnham Benefits
949.833.2983
inquiries@burnhambenefits.com


This ACA Pathways is not intended to be exhaustive nor should any discussion or opinions be construed as legal advice. Readers should contact legal counsel for legal advice. The information contained in this ACA Pathways includes emerging health care news from a limited perspective and does not encompass all views. The information was selected from a wide range of sources selected on the basis of their potential impact on employers and/or their employee benefit plans. For more information, please contact Burnham Benefits.

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