SEP's - Must Have "loss" of Coverage

[Yagents]

More and more I'm reading that in order to have an SEP, the triggering event must have caused a "loss of coverage". Meaning, if you're not insured by the end of the month, you're not getting insurance until next year.

Here is one article mentioning divorce (head of household is a new one on me - anybody know about this?):

My husband took off and now I can't get a health insurance subsidy

"Divorce doesn't trigger a special enrollment unless it results in a loss of coverage," she said, so if you're not covered to begin with, you're out of luck.

 

[cadylou]

It seems that there are no provisions within the law to address individual "special" situations either - some sort of exception or grievance process to obtain an exception to the rule. . . . .they've really botched this on so many levels. We're subsidizing many that we shouldn't, while others who really should get some help are being left out in the cold . . . .


Oh yeah! I forgot . . .none of this is about "fairness" . . . .whew! Almost got off track for a minute . . . .

 

[Ann H]

More and more I'm reading that in order to have an SEP, the triggering event must have caused a "loss of coverage". Meaning, if you're not insured by the end of the month, you're not getting insurance until next year.

Here is one article mentioning divorce (head of household is a new one on me - anybody know about this?):

My husband took off and now I can't get a health insurance subsidy

"Divorce doesn't trigger a special enrollment unless it results in a loss of coverage," she said, so if you're not covered to begin with, you're out of luck.

Included in the law are certain exceptions to the "married filing joint" issue, such as domestic violence and a missing spouse. Also, it is possible (but difficult) to qualify for a subsidy as "head of household with qualifying dependents". This is difficult and really calls for an accountant. I would also expect it to be denied by the exchange the first time, and perhaps approved on appeal.

I'm sure we will hear a lot more about SEP rules in the coming weeks, as we enter SEP season. I'm not surprised that there must be a loss of prior coverage for all qualifying events except things like marriage, birth and adoption. That's the way it is with qualifying events for group insurance.

 

[Yagents]

I'm not surprised that there must be a loss of prior coverage for all qualifying events except things like marriage, birth and adoption. That's the way it is with qualifying events for group insurance.

the way I read the attached Aetna document, you must also be insured for these 3 triggering events. It states "addition" of dependent, meaning adding onto existing plan.

 

[RayNY]

So, a "birth" is an SEP if client is currently covered and this is a "new dependent".
A "Birth" is an SEP for the child, but not the parent/family, if currently uncovered.

Stuff like return from military service/freed from incarceration/being a native indian/court order/chapter11, does not require prior coverage.

Most require previous coverage, as by definition, they are all related to a loss or change.

The only grey area is a "move" and "loss of ELIGIBILITY for subsidies", both of which do not explicitly say a plan has to be in effect.

 

[somarco]

If you have individual coverage and it lapses (for whatever reason), does that loss of coverage create an SEP?

 

[Yagents]

If you have individual coverage and it lapses (for whatever reason), does that loss of coverage create an SEP?

Only if it's involuntary lapse (plan termination). Non payment won't fly.

 

[yorkriver1]

Hi, Somarco, here's what HC.gov says: Note: Voluntarily quitting other health coverage or being terminated for not paying your premiums are not considered loss of coverage.

https://www.healthcare.gov/how-can-i-get-coverage-outside-of-open-enrollment/

 

[Yagents]

So, a "birth" is an SEP if client is currently covered and this is a "new dependent".
A "Birth" is an SEP for the child, but not the parent/family, if currently uncovered.

Stuff like return from military service/freed from incarceration/being a native indian/court order/chapter11, does not require prior coverage.

Most require previous coverage, as by definition, they are all related to a loss or change.

The only grey area is a "move" and "loss of ELIGIBILITY for subsidies", both of which do not explicitly say a plan has to be in effect.

Maybe Parole officers will become your best new referral source ?

York just posted a HC.gov link that states:

For people already enrolled in Marketplace coverage, having a change in income or household status that affects eligibility for tax credits or cost-sharing reductions

 

[Ann H]

the way I read the attached Aetna document, you must also be insured for these 3 triggering events. It states "addition" of dependent, meaning adding onto existing plan.

So, a "birth" is an SEP if client is currently covered and this is a "new dependent".
A "Birth" is an SEP for the child, but not the parent/family, if currently uncovered.

This confused me. I thought, "What? Yagents thinks birth, adoption, and marriage require prior coverage?" Then, I realized we have a miscommunication and that is what RayNY was trying to clarify.

What you are saying is that the baby who is born or adopted doesn't need to have prior coverage, to be added to an in-force policy. But if the family didn't have any insurance in force, and then a baby was born or adopted, the family can't use that as an SEP.