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Individual guaranteed issue enrollment - but only if the window is open.

Prior to the Individual Mandate provision within the Affordable Care Act, health insurance required medical underwriting in most states. This means that while there were no real restrictions to WHEN you could apply for a plan, you just had to be healthy enough to get approved. This presented individuals with enormous burdens posing the question "I have the money to pay for a policy why cant I buy one?".

There were various reasons why someone may have been uninsured when they tried to apply for an insurance plan. And of those, most had significant medical problems that prohibited them from obtaining a decent policy to help with medical costs. It was heartbreaking to explain to someone that they had no options, especially if they didn't qualify for help or alternative programs.

Flash forward to today, where regardless of your health status you can enroll into a health insurance policy. To prevent or reduce adverse selection, there needed to be a few guidelines for how these enrollments could take place. Amongst several provisions are 2 enrollment periods that I am going to explain here; Open Enrollment Period and Special Enrollment Period. A few states, such as Nevada, have amended these windows slightly but in general this is how the windows work.

Open Enrollment Period (OEP)

Initially the Open Enrollment Period was significantly longer than it will be on a standard basis. Beginning October 2013 and Ending in March 2014. This was so that the mass public could have enough time to figure it all out.

During the OEP,  individuals and families can enroll or change plans freely as long as they adhere to the effective date rules. Those rules in general state you must enroll on or before the 15th of the month for the following 1st of the month effective date. I.E: enroll by December 15 for a January 1 effective date. If you enroll between the 16th and the last day of the month then you will get the 1st of the NEXT following month. I.E: enroll on December 16 for a February 1 effective date.

Once the OEP ends you cannot make any changes and no new enrollments can be made for the uninsured unless you have a qualifying event (which I will get into shortly).

The next Open Enrollment Period will begin in November 2014 and is said to last through February 2015. The first available effective date for plan changes or enrollments is January 1 2015.

Special Enrollment Period (SEP)

After the Open Enrollment Period ends, the Special Enrollment Period begins. During this time you must have a qualifying event in order to enroll in a new plan. A qualifying event would be a life event such as losing coverage from an employer, moving to a new region, marriage, birth or even a significant change in income.

Typically for almost all of the qualifying events you will have a short 60 day window to enroll or change your plan. Within that 60 day window you are still subject to the effective date rules as mentioned previously.

Each insurance carrier has their specific list of qualified proof of qualifying event documents. As does the state health insurance exchange.

If you fail to enroll in a new plan within the 60 days, you may still have options. In that situation I advise calling the state exchange directly to speak to a representative that can assist you. 

If you find yourself outside of the OEP and SEP without options and want to insure against a catastrophic risk, I would consider a temporary medical policy. These are not Affordable Care Act compliant and you may still be penalized for not having a qualified insurance plan but at least you are safeguarding yourself from serious financial risk. The time periods range from 30 to 180 days and are customizable with regard to deductible and out of pocket maximum.

Penalties for not having insurance

Many people are still not aware that if you are without Minimum Essential Coverage for more than 90 continuous days, you could be penalized on your tax return. Each year the penalty goes up and it is on a sliding scale based on income and assessed for each person in your household.

For more in depth details that pertain to your specific situation, contact me anytime. I'd love to discuss your needs.

For a list of carriers we work with please click HERE

-Jolene Bibian, Vice President of LRA, Inc.



Jolene Bibian