Source: https://individuals.healthreformquotes.com/open-enrollment-for-individuals-families/ccr-code-regulations-ca-%C2%A76504-special-enrollment-periods/special-enrollment-triggering-events/zspecial-enrollment-pre-4-2017-cms-9929-f-historical/
Timestamp: 2019-11-14 19:01:05
Document Index: 189420591

Matched Legal Cases: ['§6504', '§155', '§155', '§10965', '§ 155', '§155', '§156', '§156', '§155', '§155', '§155', '§155', 'art 156', '§155', '§ 54']

Special Enrollment pre-4.2017 * CMS 9929 F * Historical Health Insurance Special Enrollment pre-4.2017 * CMS 9929 F * Historical Health Insurance
Home › Open Enrollment & Special Enrollment › §6504 Special Enrollment Periods CCR California Code of Regulations › CFR §155.420 Federal Qualifying Events, Triggers › zSpecial Enrollment pre-4.2017 * CMS 9929 F * Historical
Special Enrollment Rules – Western Poverty Center
HCC Short Term Medical – Missed Open Enrollment?
Market Stabilization PDF – New stricter rules 7.2017? more vetting of special enrollments
This page is Historical –
Click here for Current Info
Qualifying Event – Triggers (QLE, SEP)
Want to get coverage now rather than wait till November to pick a plan for January?
Review the special reasons listed below and brochures at the right:
5.6.2016 Fact Sheet on Updates
2017 CFR Updates
Final Rule CMS 9929 F Modern Health Care 4.13.2017 * CMS.Gov 4.13.2017 * Amazonaws.com
Donald’s Rule CMS -9929 – P 71 Pages will limit and implement much more vetting. Learn More
Commentary & Explanation Insure Me Kevin.com
Covered CA 2017 Special Enrollment Toolkit
Simplified Blue Shield Summary Chart in pdf.
Please note that these pages includes both in and out of Covered CA and both Individual and Employer Plans (Employer Info on Late Enrollment)
Be sure to check the application and/or the footnotes & CFR’s very carefully or just email all your documents to us for review.
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If you don’t find a trigger you are pretty much SOL.
Temporary Plan – NO Trigger Required
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REASONS – TRIGGERS
CFR §155.420 Special enrollment periods Copied 2.16.2016 See also CA Insurance Code §10965.3 (d) (1) Effective Date
(d) § 155.420 see below for 2017 updates… The Exchange must allow a qualified individual or enrollee, and, when specified below, his or her dependent, to enroll in or change from one QHP to another if one of the following triggering events occur:
Court order [definition] – mandate to be covered as a dependent (Note – When a divorce is filed, there is a prohibition from deleting spouse and children! FL 110 Legal Treatise Attorney Website on Divorce Automatic Orders)
(ii) Effective January 1, 2017 or earlier at the option of the Exchange, the enrollee loses a dependent or is no longer considered a dependent through divorce or legal separation as defined by State law in the State in which the divorce or legal separation occurs, or if the enrollee, or his or her dependent, dies.
(3) The qualified individual, or his or her dependent, which was not previously a citizen, national, or lawfully present individual gains such status;
No more special enrollment for
Documented immigrants who experienced “system errors” during the federal government’s determination of their advance tax credit payments; and
Documented immigrants with incomes below 100% of the federal poverty level who faced “processing delays” (Counihan, CMS blog, 1/19). Learn More ⇒CA Health Line – Health Affairs.org 1.20.2016
(4) The qualified individual’s or his or her dependent’s, enrollment or non-enrollment in a QHP is unintentional, inadvertent, or erroneous and is the result of the error, misrepresentation, misconduct, or inaction
(6) Newly eligible or ineligible for advance payments of the premium tax credit, or change in eligibility for cost-sharing reductions. [enhanced-silver]
(7) The qualified individual or enrollee, or his or her dependent, gains access to new QHPs as a result of a permanent move;
(8) The qualified individual who is an Indian, as defined by section 4 of the Indian Health Care Improvement Act, may enroll in a QHP or change from one QHP to another one time per month;
(9) The qualified individual or enrollee, or his or her dependent, demonstrates to the Exchange, in accordance with guidelines issued by HHS, that the individual meets other exceptional circumstances as the Exchange may provide.
In recent days Anthem, Aetna and Cigna, all among the top five health insurers, told brokers they will stop paying them sales commissions to sign up most customers who qualify for new coverage outside the normal enrollment period, according to the companies and broker documents. Learn More – CA HealthLine 1.4.2016 Covered CA to require Insurer’s pay commissions CA Health Line 2.18.2016
(1) The Exchange must provide special enrollment periods consistent with this section, during which qualified individuals may enroll in QHPs [Qualified Health Plan] and enrollees may change QHPs.
(2) For the purpose of this section, “dependent”, has the same meaning as it does in 26 CFR 54.9801-2, referring to any individual who is or who may become eligible for coverage under the terms of a QHP because of a relationship to a qualified individual or enrollee.
(b) Effective dates—
(c) Availability and length of special enrollment periods—
(1) General rule. Unless specifically stated otherwise herein, a qualified individual or enrollee has 60 days from the date of a triggering event to select a QHP.
(2) Advanced availability. A qualified individual or his or her dependent who is described in paragraph (d)(1) or (d)(6)(iii) or, beginning on January 1, 2017 or earlier at the option of the Exchange, paragraph (d)(7) of this section, has 60 days before and after the triggering event to select a QHP. Prior to January 1, 2017, a qualified individual or his or her dependent who is described in paragraph (d)(7) of this section may select a QHP in accordance with paragraph (c)(1) of this section.
(3) Special rule. In the case of a qualified individual or enrollee who is eligible for a special enrollment period as described in paragraphs (d)(4), (5), or (9) of this section, the Exchange may define the length of the special enrollment period as appropriate based on the circumstances of the special enrollment period, but in no event may the length of the special enrollment period exceed 60 days.
[77 FR 18444, Mar. 27, 2012, as amended at 78 FR 42321, July 15, 2013; 78 FR 65095, Oct. 30, 2013; 79 FR 30348, May 27, 2014; 79 FR 59138, Oct. 1, 2014; 80 FR 10866, Feb. 27, 2015; 80 FR 38653, July 7, 2015]
2017 Updates – They may or may not apply to Covered CA
§155.420 2017 updates Special enrollment periods.
(a) General requirements—
Enrollee means a qualified individual or qualified employee enrolled in a QHP. Enrollee also means the dependent of a qualified employee enrolled in a QHP through the SHOP, and any other person who is enrolled in a QHP through the SHOP, consistent with applicable law and the terms of the group health plan. Provided that at least one employee enrolls in a QHP through the SHOP, enrollee also means a business owner enrolled in a QHP through the SHOP, or the dependent of a business owner enrolled in a QHP through the SHOP.
Qualified individual means, with respect to an Exchange, an individual who has been determined eligible to enroll through the Exchange in a QHP in the individual market. Definitions 155.20
(2) Definition of dependent. For the purpose of this section, “dependent”, has the same meaning as it does in 26 CFR 54.9801-2, referring to any individual who is or who may become eligible for coverage under the terms of a QHP because of a relationship to a qualified individual or enrollee.
(3) Use of special enrollment periods. Except in the circumstances specified in paragraph (a)(4) of this section, the Exchange must allow a qualified individual or enrollee, and when specified in paragraph (d) of this section, his or her dependent to enroll in a QHP if one of the triggering events specified in paragraph (d) of this section occur.
(4) Use of special enrollment periods by enrollees.
(i) If an enrollee has gained a dependent in accordance with paragraph (d)(2)(i) of this section, the Exchange must allow the enrollee to add the dependent to his or her current QHP, or, if the current QHP’s business rules do not allow the dependent to enroll, the Exchange must allow the enrollee and his or her dependents to change to another QHP within the same level of coverage (or one metal level higher or lower, if no such QHP is available), as outlined in §156.140(b) of this subchapter, or, at the option of the enrollee or dependent, enroll the dependent in any separate QHP.
(iii) If an enrollee qualifies for a special enrollment period or is adding a dependent to his or her QHP through a triggering event specified in paragraph (d) of this section other than those described under paragraph (d)(2)(i), (d)(4), (d)(6)(i), (d)(6)(ii), (d)(8), (d)(9), or (d)(10), the Exchange must allow the enrollee and his or her dependents to make changes to his or her enrollment in the same QHP or to change to another QHP within the same level of coverage (or one metal level higher or lower, if no such QHP is available), as outlined in §156.140(b) of this subchapter, or, at the option of the enrollee or dependent, enroll in any separate QHP.
(5) Prior coverage requirement. Qualified individuals who are required to demonstrate coverage in the 60 days prior to a qualifying event can either demonstrate that they had minimum essential coverage as described in 26 CFR 1.5000A-1(b) for 1 or more days during the 60 days preceding the date of the qualifying event; lived in a foreign country or in a United States territory for 1 or more days during the 60 days preceding the date of the qualifying event; or that they are an Indian as defined by section 4 of the Indian Health Care Improvement Act.
(1) Regular effective dates. Except as specified in paragraphs (b)(2), (3), and (5) of this section, for a QHP selection received by the Exchange from a qualified individual—
(2) Special effective dates.
(iv) If a consumer loses coverage as described in paragraph (d)(1) or (d)(6)(iii) of this section, gains access to a new QHP as described in paragraph (d)(7) of this section, becomes newly eligible for enrollment in a QHP through the Exchange in accordance with §155.305(a)(2) as described in paragraph (d)(3) of this section, or becomes newly eligible for advance payments of the premium tax credit in conjunction with a permanent move as described in paragraph (d)(6)(iv) of this section, if the plan selection is made on or before the day of the triggering event, the Exchange must ensure that the coverage effective date is on the first day of the month following the date of the triggering event. If the plan selection is made after the date of the triggering event, the Exchange must ensure that coverage is effective in accordance with paragraph (b)(1) of this section or on the first day of the following month, at the option of the Exchange.
(3) Option for earlier effective dates. Subject to the Exchange demonstrating to HHS that all of its participating QHP issuers agree to effectuate coverage in a timeframe shorter than discussed in paragraph (b)(1) or (b)(2)(ii) of this section, the Exchange may do one or both of the following for all applicable individuals:
(4) Advance payments of the premium tax credit and cost-sharing reductions. Notwithstanding the standards of this section, the Exchange must ensure that advance payments of the premium tax credit and cost-sharing reductions adhere to the effective dates specified in §155.330(f).
(5) Option for later coverage effective dates due to prolonged eligibility verification. At the option of the consumer, the Exchange must provide for a coverage effective date that is no more than 1 month later than the effective date specified in this paragraph (b) if a consumer’s enrollment is delayed until after the verification of the consumer’s eligibility for a special enrollment period, and the assignment of a coverage effective date consistent with this paragraph (b) would result in the consumer being required to pay 2 or more months of retroactive premium to effectuate coverage or avoid cancellation.
(2) Advanced availability. A qualified individual or his or her dependent who is described in paragraph (d)(1) or (d)(6)(iii) of this section has 60 days before or after the triggering event to select a QHP. At the option of the Exchange, a qualified individual or his or her dependent who is described in paragraph (d)(7) of this section; who is described in paragraph (d)(6)(iv) of this section and becomes newly eligible for advance payments of the premium tax credit as a result of a permanent move to a new State; or who is described in paragraph (d)(3) of this section and becomes newly eligible for enrollment in a QHP through the Exchange because he or she newly satisfies the requirements under §155.305(a)(2), has 60 days before or after the triggering event to select a QHP.
(d) Triggering events. Subject to paragraphs (a)(3) through (5) of this section, as applicable, the Exchange must allow a qualified individual or enrollee, and, when specified below, his or her dependent, to enroll in or change from one QHP to another if one of the triggering events occur:
(iii) Loses pregnancy-related coverage described under section 1902(a)(10)(A)(i)(IV) and (a)(10)(A)(ii)(IX) of the Act (42 U.S.C. 1396a(a)(10)(A)(i)(IV), (a)(10)(A)(ii)(IX)). The date of the loss of coverage is the last day the consumer would have pregnancy-related coverage; or
(3) The qualified individual, or his or her dependent, becomes newly eligible for enrollment in a QHP through the Exchange because he or she newly satisfies the requirements under §155.305(a)(1) or (2);
(4) The qualified individual’s or his or her dependent’s, enrollment or non-enrollment in a QHP is unintentional, inadvertent, or erroneous and is the result of the error, misrepresentation, misconduct, or inaction of an officer, employee, or agent of the Exchange or HHS, its instrumentalities, or a non-Exchange entity providing enrollment assistance or conducting enrollment activities. For purposes of this provision, misconduct includes the failure to comply with applicable standards under this part, part 156 of this subchapter, or other applicable Federal or State laws as determined by the Exchange.
(7) The qualified individual or enrollee, or his or her dependent, gains access to new QHPs as a result of a permanent move and—
(8) The qualified individual—
(10) A qualified individual or enrollee—
(11) A qualified individual or dependent—
(i) Applies for coverage on the Exchange during the annual open enrollment period or due to a qualifying event, is assessed by the Exchange as potentially eligible for Medicaid or the Children’s Health Insurance Program (CHIP), and is determined ineligible for Medicaid or CHIP by the State Medicaid or CHIP agency either after open enrollment has ended or more than 60 days after the qualifying event; or
(12) The qualified individual or enrollee, or his or her dependent, adequately demonstrates to the Exchange that a material error related to plan benefits, service area, or premium influenced the qualified individual’s or enrollee’s decision to purchase a QHP through the Exchange; or
(13) At the option of the Exchange, the qualified individual provides satisfactory documentary evidence to verify his or her eligibility for an insurance affordability program or enrollment in a QHP through the Exchange following termination of Exchange enrollment due to a failure to verify such status within the time period specified in §155.315 or is under 100 percent of the Federal poverty level and did not enroll in coverage while waiting for HHS to verify his or her citizenship, status as a national, or lawful presence.
(e) Loss of coverage. Loss of coverage described in paragraph (d)(1) of this section includes those circumstances described in 26 CFR 54.9801-6(a)(3)(i) through (iii) and in paragraphs (d)(1)(ii) through (iv) of this section. Loss of coverage does not include voluntary termination of coverage or other loss due to—
[77 FR 18444, Mar. 27, 2012, as amended at 78 FR 42321, July 15, 2013; 78 FR 65095, Oct. 30, 2013; 79 FR 30348, May 27, 2014; 79 FR 59138, Oct. 1, 2014; 80 FR 10866, Feb. 27, 2015; 80 FR 38653, July 7, 2015; 81 FR 29155, May 11, 2016; 81 FR 94178, Dec. 22, 2016; 82 FR 18381, Apr. 18, 2017]
Covered CA – What is Special Enrollment 2:23 Minutes
Center on Budget and Policy circumstances that trigger a special enrollment period that allow consumers to change or newly enroll in health coverage outside of open enrollment
Covered CA Special Enrollment Qualification – Rap Video
This short presentation will walk you through a scenario that will help address some questions that may come up when you’re counseling consumers who lose their job-based coverage.
The Rule Making Process 11 pages pdf
Returning from active duty of the reserve forces of the United States military or the California National Guard
Just Informed of Tax Penalty Risk and didn’t know about it before
(A) He or she or his or her dependent loses minimum essential coverage.
(G) He or she was receiving services from a contracting provider under another health benefit plan, as defined in Section 10965 of this code or Section 1399.845 of the Health and Safety Code, for one of the conditions described in subdivision (a) of Section 10133.56 of this code and that provider is no longer participating in the health benefit plan.
CA Code of Regulations 6504 Special Enrollment Periods
Citations – More details
Excerpt from CIGNA 2014 Enrollment Application
Oscar SEP Guidelines * More Detail * 3.9.2017 Update
CA Agent Training Page 9
Specimen EOC Page 28
CFR § 54.9801-6
Health & Safety Code 1399.849 ♦
Health Net Group Manual ♦
Federal Guidance 3.24.2014
(Employer Info on Late Enrollment)
Covered CA Special Enrollment rules
Kaiser Individual 2015 Form
Anthem Blue Cross Summary Grid 9.2015? of documentation required
HN 7.29.2014 Bulletin
We’ve strengthened our rules and clarified our processes for SEPs, so that the people who need to can still easily get coverage, while making it hard for anyone thinking about taking advantage. We also eliminated 7 SEPs, including the SEP for individuals who paid the tax penalty for not having health insurance, contributing to an almost 30 percent year-over-year drop in the number of SEP enrollments during the three months after Open Enrollment. CMS Fact Sheet 6.8.2016
Covered CA Job aid for 2.16.2015 going forward, webpage for Qualifying Events. Two page flyer
Covered CA – 2015 Special Enrollment Qualifying Life Events – List
4.24.2015 Special Enrollment – How to complete ONLINE application
Insure Me Kevin.com – 2015 Penalties?
Please note too that Blue Cross and it appears all companies Emails dated 1.21.2015 2:07 PM will make coverage effective 1st of the month following the application rather then the crazy 15th and miss a month deadline.
Enrollment Applications – Individual – Small Group
Agent Training – Covered CA
Agent Website Chatter
Los Angeles Times Documentation not required in 2014
Kaiser Foundation FAQ’s
AB 1461 Small EmployER Health – Non Grandfathered Requirements Triggering Events AB 1461
10753.05 (3) A carrier shall provide enrollment periods consistent with PPACA and set forth in Section 155.725 of Title 45 of the Code of Federal Regulations.
A carrier shall provide special enrollment periods consistent with the special enrollment periods required in the individual non grandfathered market in the state, as set forth in Section 10965.3, [AB 1461]except for the triggering events identified in paragraphs (d)(3) and (d)(6) of Section 155.420 of Title 45 of the Code of Federal Regulations with respect to health benefit plans offered through the Exchange.
Qualifying events are only observed outside of open enrollment.
During open enrollment everyone is on the same effective date schedule regardless of qualifying event (except newborns). If application is received the 15th or before, effective date is first of the month following. If received after the 15th, effective date is first of the second month following. From BC Email dated 3.7.2014
Blue Shield – More Info
Wording from HN ONLINE application
Please check the box next to any Qualifying Event(s) that happened within the last 60 days:
The qualified individual, or his or her dependent, loses minimum essential coverage, which could be due to one of the following reasons (not including voluntary termination of your previous coverage or termination due to failure to pay premiums):
The termination or reduction of hours, of the covered employee’s employment.
The covered employee becoming entitled to benefits under Medicare.
A proceeding in a case under title 11 bankruptcy, commencing on or after July 1, 1986, with respect to the employer from whose employment the covered employee retired at any time. In this case, a loss of coverage includes a substantial elimination of coverage with respect to a qualified beneficiary (spouse/domestic partner, dependent child or surviving spouse /domestic partner) within one year before or after the date of commencement of the proceeding.
Loss of minimum essential coverage for any reason other than failure to pay premiums or situations allowing for a rescission for fraud or intentional misrepresentation of material fact.
Termination of employer contributions.
Exhaustion of COBRA continuation coverage.
The qualified individual gains a dependent or becomes a dependent through marriage, domestic partnership, birth, adoption, placement for adoption, or the assumption of a parent-child relationship.
The qualified individual’s, or his or her dependent’s, enrollment or non-enrollment in a health plan is unintentional, inadvertent, or erroneous and is the result of the error, misrepresentation, or inaction of an officer, employee, or agent of the Exchange or HHS, or its instrumentalities as evaluated and determined by the Exchange.
The health plan in which the enrollee, or his or her dependent, is enrolled substantially violated a material provision of its contract.
The qualified individual or enrollee, or his or her dependent, gains access to a new health plan as a result of a permanent move.
With respect to individuals enrolled in non-calendar year individual health insurance policies, a limited open enrollment period beginning on the date that is 30 calendar days prior to the date the policy year ends in 2014.
He or she is mandated to be covered as a dependent pursuant to a valid state or federal court order.
He or she has been released from incarceration.
He or she was receiving services under another health benefit plan, from a contracting provider who is no longer participating in that health plan, for any of the following conditions: (a) an acute condition (a medical condition that involves a sudden onset of symptoms due to an illness, injury, or other medical problem that requires prompt medical attention and that has a limited duration); (b) a serious chronic condition (a medical condition due to a disease, illness, or other medical problem or medical disorder that is serious in nature and that persists without full cure or worsens over an extended period of time or requires ongoing treatment to maintain remission or prevent deterioration); (c) a terminal illness (an incurable or irreversible condition that has a high probability of causing death within one year or less); (d) a pregnancy; (e)care of a newborn between birth and 36 months; or (f) a surgery or other procedure that has been recommended and documented by the provider to occur within 180 days of the contract’s termination date, or within 180 days of the effective date of coverage for a newly covered insure, and that provider is no longer participating in the health plan.
He or she demonstrates to the Exchange, with respect to health benefit plans offered through the Exchange, or to the California Department of Insurance, with respect to health plans offered outside the Exchange, that he or she did not enroll in a health benefit plan during the immediate preceding enrollment period available to the individual because he or she was misinformed that he or she was covered under minimum essential coverage.
He or she is a member of the reserve forces of the United States military returning from active duty or a member of the California National Guard returning from active duty service under Title 32 of the United States Code.
Newly eligible or ineligible for advance payments of the premium tax credit, or change in eligibility for cost-sharing reductions.
He or she loses medically needy coverage under Medicaid (not including voluntary termination of your previous coverage or termination due to failure to pay premium).
He or she loses pregnancy-related coverage under Medicaid (not including voluntary termination of your previous coverage or termination due to failure to pay premium).