Judy Kamens Compliance Specialist View Bio

Exchange Health Insurance Enrollment

May 22, 2013

The Affordable Care Act (ACA) calls for the creation of state-based competitive marketplaces, known as Affordable Health Insurance Exchanges (Exchanges), for individuals and small businesses to purchase private health insurance and qualify for premium tax credits and other affordability programs. ACA requires the Exchanges to become operational in 2014 with enrollment for eligible individuals and small businesses expected to begin on Oct. 1, 2013.

An individual will be eligible for enrollment in a “qualified health plan” (QHP) through an Exchange if he or she:

  • Is a citizen, national or non-citizen lawfully present in the U.S., and is reasonably expected to remain so for the entire period for which enrollment is sought;
  • Is not incarcerated; and
  • Resides in the state covered by the Exchange.

Each Exchange will determine whether an individual meets the eligibility standards for enrollment. After the Exchange determines eligibility, the Exchange will provide the individual with a timely, written notice of his or her eligibility determination.

ENROLLMENT PERIODS

The ACA requires Exchanges to have an initial open enrollment period, an annual open enrollment period and certain special enrollment periods. Individuals will only be able to enroll in a QHP through an Exchange during one of the permitted enrollment periods.

-Initial Enrollment Period

The initial open enrollment period is expected to run from Oct. 1, 2013, through March 31, 2014. Coverage must be offered effective Jan. 1, 2014, for qualified individuals whose QHP selections are received by the Exchange on or before Dec. 15, 2013. For selections received between the first and 15th day of January, February or March 2014, coverage must be provided effective the first day of the following month. For those received between the 16th day and the last day of any month between December 2013 and March 31, 2014, the Exchange must ensure coverage is effective the first day of the second following month.

-Special Enrollment Periods

Health care reform requires Exchanges to offer special enrollment periods. Under final Exchange regulations, the Exchanges must allow qualified individuals and enrollees to enroll in a QHP or change from one to another as a result of the following triggering events:

  • A qualified individual or dependent loses minimum essential coverage;
  • A qualified individual gains a dependent or becomes a dependent through marriage, birth, adoption, or placement for adoption;
  • An individual, who was not previously a citizen, national, or lawfully present individual gains such status;
  • A qualified individual’s enrollment or non-enrollment in a QHP is unintentional, inadvertent, or erroneous and is the result of the error, misrepresentation, or inaction of the Exchange or HHS;
  • An enrollee adequately demonstrates to the Exchange that the QHP in which he or she is enrolled substantially violated a material provision of its contract in relation to the enrollee;
  • An individual is determined newly eligible or newly ineligible for advance payments of the premium tax credit or has a change in eligibility for cost-sharing reductions, regardless of whether such individual is already enrolled in a QHP. (The Exchange must permit individuals whose existing coverage through an eligible employer-sponsored plan will no longer be affordable or provide minimum value for his or her employer’s upcoming plan year to access this special enrollment period prior to the end of his or her coverage through such eligible employer-sponsored plan);
  • A qualified individual or enrollee gains access to new QHPs as a result of a permanent move;
  • An Indian may enroll in a QHP or change from one to another one time per month; and
  • A qualified individual or enrollee demonstrates to the Exchange that the individual meets other exceptional circumstances (as defined by the Exchange).

The special enrollment period generally is 60 days from the date of the triggering event. Coverage must be effective as of the first day of the following month for elections made by the 15th of the preceding month and on the first day of the second following month for elections made between the 16th and the last day of a month (but coverage must be effective on the date of birth, adoption, or placement for adoption, when that is the special enrollment triggering event).

-Annual Enrollment Periods

The annual enrollment period for 2015 and subsequent years will begin October 15 and extend through December 7 of the preceding calendar year. Starting in 2014, the Exchange must provide advance written notice to each enrollee about annual open enrollment no earlier than September 1, and no later than September 30.

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Exchange Health Insurance Enrollment

This Legislative Brief 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.