1. The HEALTH INSURANCE MARKETPLACE: Special Enrollment Periods
ACA
Name
Enroll VA Title
Work Address
T: Work Number

2. enrollment period
When eligible individuals can enroll in a Qualified Health Plan (QHP)
Marketplace will determine eligibility to enroll in a plan, determine eligibility for financial assistance and assess eligibility for Medicaid
A person can only enroll in a QHP during Open Enrollment or during a Special Enrollment Period
Applies to QHPs on the Marketplace and those off the Marketplace
Medicaid has year round enrollment

3. Open Enrollment Periods
Annual period when qualifying individuals can apply and enroll in a health plan
Qualifying individual is someone who:
Lives in the service area
Is not currently incarcerated
U.S. citizen, national, or will be lawfully present for the entire time coverage is sought
Open enrollment for 2017 coverage: November1, 2016 – January 31, 2017
Open enrollment for 2018 coverage: November 1, January 31, 2018*
Open enrollment for 2019 coverage: November 1, 2018 – Dec.15, 2018
* A proposed rule would change these dates to November 1, 2017 – Dec. 15, 2017

4. Special Enrollment Periods
Enable individuals who experience certain qualifying life events to enroll in or change plans outside of Open Enrollment
Can occur at any point during the year
Usually gives someone 60 days to take action
Usually applies to the entire family, even if only one person experiences the change
Some are available to anyone and some are only available to those who are already enrolled in a Marketplace plan

5. Qualifying life events For anybody
Loss of Minimum Essential Coverage because:
A family member’s death
Turned 26 and could no longer be on parent’s plan
Lost dependent status
Left or terminated from a job
Lost eligibility for CHIP or Medicaid benefits
Expiration of COBRA coverage
Got a divorce
Employer no longer offers coverage
Employer coverage is no longer affordable or adequate
Non-marketplace plan expired
Lost eligibility for a student plan
Does not include voluntary terminations or cancelation for non-payment of premiums

6. Qualifying life events For anybody, cont’d
Permanent Move
Resulting in access to new qualified health plans
A short-term move for medical treatment or vacation is not considered a permanent move
A child or dependent moves back to parent’s home
A person moves to a different area for seasonal employment, but maintains another home elsewhere (such as seasonal formwork)
Moving to the U.S. from abroad or a U.S. territory
Must have had coverage for at least 1 day in the previous 60 days unless moving from abroad

7. Qualifying life events For anybody, cont’d
Marriage
Birth or adoption, if child is Marketplace eligible
Gained eligible immigration status
Left incarceration
Income was below 100% FPL during Open Enrollment and is now above 100% FPL
Survivor of domestic violence or spousal abandonment and is enrolled in a QHP, but wants to enroll in a plan separate from abuser or spouse
Native American & Alaska Native (1x per month)
Applied for Medicaid during Open Enrollment but was denied after Open Enrollment ended

8. Example: income increase above 100% fpl
Jane (a household of one) was unemployed during Open Enrollment so her income estimate was $0. In June, Jane finds a job that will pay her approximately $36,000/yr. Can Jane attest that she will be make more than 100% FPL ($11,880 for a household of 1) between June and December 2017?
January
June
December
Yes! She will receive around $18,000 for the 2016 calendar year.

9. Qualifying life events For anybody, cont’d
Complex Issues
I was negatively impacted by an error, misrepresentation, misconduct or inaction by the Marketplace or other entity providing enrollment assistance (ex. Navigator, CAC, insurance company)
Plan or benefit display error
Exceptional Circumstances prevented enrollment
Serious medical condition
Natural disaster
Winning a Marketplace Appeal

10. Qualifying Life Events for Enrollees
Change in income
Enrollee is newly eligible or ineligible for Premium Tax Credits
Enrollee is newly eligible or ineligible for cost- sharing reductions
Enrollee demonstrates plan violated contract

11. Not qualifying life events
Voluntarily dropping other coverage
Loss of eligibility for coverage when the person was not enrolled in it (i.e., loses job, but was not in the employer’s health plan)
Being determined newly eligible for PTC if not already enrolled in a Marketplace QHP (unless coming out of the Medicaid coverage gap)
Being terminated from other coverage for not paying premiums or for fraud
Divorce or death of a family member if person does not also lose coverage as a result
Becoming pregnant
Moving within the U.S. if the person did not have coverage in at least one day in the past 60 days

12. How to apply
Standard Application can be used to apply for and be granted most Special Enrollment Periods
Those already enrolled in marketplace coverage must update their original application
Those not enrolled in Marketplace coverage can go to the Marketplace and start a new application
Marketplace Call Center & CMS Casework must be used to access SEPs for:
Income increasing over 100% FPL
Complex Issues
Exceptional Circumstances
Survivor of domestic violence or spousal abandonment

13. How to Apply: Multiple “doors”
Online
Marketplace
Marketplace Call Center
Local assistance
Enroll Virginia –
Medicaid applications can be done year round online, through the Cover VA call center or at your local DSS
www. commonhelp.virginia.gov

14. Information Needed to Apply
Identity of applicants
Names and contact info
Social Security Numbers
Immigration Status and Documents
Household Size
Using tax code principles to determine household size
Tax dependents are in the tax filers household
Estimated 2017 income
Modified Adjustable Gross Income (MAGI)
Adjusted Gross Income + non-taxable Social Security benefits + tax- exempt interest + tax-exempt foreign income
Availability of employer-based coverage and it’s cost
Proof of qualifying life event
Databases will verify most information, paper documents used for discrepancies

15. When to apply
All SEPs are available 60 days after the qualifying life event
You must apply and enroll before the 60 days ends
Loss of Coverage SEP can be accessed 60 days before or 60 days after the loss of coverage, this can help avoid a gap in coverage

16. Eligibility
Once an application is completed, you will get an eligibility determination notice that will inform you of:
Your eligibility for a special enrollment period
The dates of your special enrollment period
Your eligibility for financial assistance
Is any documents must be submitted
You can then enroll in or switch plans

17. Eligibility For Financial Assistance
Premium tax credits
reduce the amount you pay for your premium. Must have income between 100% and 400% FPL.
Cost sharing reductions lower your deductibles, co-pays and out of pocket costs. Must have income between 100% and 250% FPL.

18. 2016 Federal Poverty Guidelines
Note: Medicaid applications will be assessed using 2017 thresholds

19. Effective dates Normal effective dates apply with few exceptions
If you enroll by the 15th of a month, the coverage will being the 1st of the next month
If you enroll after the 15th of a month, the coverage will being the 1st of the second following month
Exceptions
Loss of coverage if SEP accessed before the loss occurs
1st day of month following plan selection
Marriage and death
Birth/adoption/placement in foster care - enrollee can choose:
Date of birth/adoption/placement, or
1st day of the month after birth/adoption/placement, or
Regular coverage effective dates

20. Post-enrollment verification
Some SEPS require proof of eligibility to be submitted. Enrollees will be able to enroll at time of application, but must submit required documents within 30 days or risk losing coverage for:
Loss of minimum essential coverage
Proof of previous coverage and date of loss
Permanent move
Old address
New address
Proof of previous coverage
Birth
Adoption, placement for adoption, placement or foster care or child support or other court order
Marriage

21. Pre-enrollment verification Pilot Program
Beginning in June 2017, the Marketplace will require 50% of SEP applicants to submit proof of SEP eligibility before they will be allowed to enroll in coverage.
All SEP types will be subject to verification.
Effective date will usually be determined by the date of plan selection. The enrollment will be pending until the individual submits documents.
There will be situations where consumers can request a prospective coverage effective date if verification is delayed for 2 months or longer.
The consumer will have 30 days to submit requested documents, if documents are not received the consumer will not be enrolled in the plan.
The consumer must pay your first premium for the coverage to begin once their eligibility has been verified.

22. Exemptions & Penalty
If you do not access an SEP and go without coverage you may have to pay a penalty
Everyone is required to have minimum essential coverage (MEC), pay a penalty, or get an exemption
Taxpayer is responsible for dependents
Coverage requirement, penalties, and most exemptions apply on a monthly basis
One day rule:
A person has coverage entire month if covered for at least one day of that month
A person is eligible for an exemption entire month if they are exempt for at least one day of that month.
2017 penalty is $695 per adult + $ per child up to $2085 or 2.5% family income above the tax filing threshold

23. Exemptions Granted by Marketplace Granted at Tax Filing
Hardship, including:
Experienced homelessness, an eviction or foreclosure, or received a utility shut off notice.
Bankruptcy
Victim of domestic violence
Determined ineligible for Medicaid in a state that did not expand Medicaid coverage 
Plan cancellation
Member of certain religious sects
Other
Insurance in unaffordable based on projected income
Granted at Tax Filing
Income below filing threshold
Insurance is unaffordable
Certain noncitizens
Short coverage gap (<3 months)
Gap before effective date of Marketplace coverage purchased during open enrollment
Having income below 138% FPL in a state that did not expand Medicaid
Health care sharing ministry
Indian tribe membership
Incarceration
US citizen living abroad for more than 330 day in the year
An exemption for a state’s failure to expand Medicaid can be received by applying for coverage directly at healthcare.gov if you are below 100% FPL

24. QUESTIONS? Phone Number email@enroll-virginia.com
@EnrollVirginia

25. Thank you!
ENROLL Virginia! is a nonprofit, nonpartisan entity that assists individuals and small businesses to obtain health insurance including commercial health coverage through the federally facilitated health insurance marketplace, to qualify for applicable tax subsidies, and to comply with the U.S. Patient Protection and Affordable Care Act and avoid penalties for failure to do so. The program is paid for by a federal grant (Funding Opportunity Number CA- NAV from the U.S. Department of Health and Human Services, Centers for Medicare & Medicaid Services)  and administered by the Virginia Poverty Law Center.  The contents provided here are solely the responsibility of the authors and do not necessarily represent the official views of HHS or any of its agencies.
“This project is supported by the U.S. Department of Health and Human Services, FOA CA-NAV from CMS.  The contents provided are solely the responsibility of the authors and do not necessarily represent the official views of HHS or any of its agencies.”