Special Enrollment Periods (SEPs)

1. Special Enrollment Periods (SEPs)

2. How do I enroll in coverage now that Open Enrollment for 2014 is over? • There are two reasons you may be eligible for a Special Enrollment Period to purchase individual or family coverage on the federal Marketplace: • You have had a “Qualifying Life Event,” or • You attempted to enroll but could not complete the process before March 31 due to a “complex issue” • If you are granted a Special Enrollment Period, you will have 60 days to pick a plan. • Medicaid enrollment is open all year for qualifying individuals. • SHOP Marketplace enrollment is open all year for qualifying small businesses

3. What is a Qualifying Life Event? • A Qualifying Life Event (QLE)is a change in your circumstances that makes you eligible for a Special Enrollment Period to enroll in health coverage. • With a Special Enrollment Period you can enroll or make changes to your plan outside of Open Enrollment Period.

4. Examples of a Qualifying Life Event • Getting married • Having a baby, adopting a child or placing a child for adoption or foster care • Moving outside your insurer’s coverage area- call your insurance company for more details • Gaining citizenship or eligible immigration status • Leaving incarceration • Involuntarily losing other health coverage. Examples include: • Job loss • Expiration of COBRA • Divorce • End of individual policy plan year in 2014 (regardless of whether the plan is canceled or up for renewal) • Aging out of a parent’s plan – turning 26 • Losing Medicaid/CHIP eligibility • For people already enrolled in Marketplace plan: Having a change in household status or income that affects eligibility for financial help.

5. Do I qualify for an SEP if I voluntarily dropped coverage? • If you voluntarily drop your coverage or lose it because you didn’t pay the premium, you do not qualify for a Special Enrollment Period. • This means you will not be able to get covered through the Marketplace until the next Open Enrollment Period in November 2014, with coverage starting January 1, 2015, unless you experience another Qualifying Life Event.

6. How do I apply for Marketplace coverage if I have a Qualifying Life Event? • If you have experienced a life-changing event and need coverage, there are several ways you can take the first step to getting covered. • Call the Get Covered Illinois Help Desk at (866) 311-1119 from 8 AM to 8 PM Monday-Saturday to talk to a specialist. • You can also visit GetCoveredIllinois.gov to find a Navigatoror Agent

7. Can my partner and I apply for coverage through a Special Enrollment Period if we convert our civil union to a marriage? • Yes. Starting June 1, 2014, and through the first year that the Illinois Religious Freedom and Marriage Fairness Act goes into effect you will be able to convert your civil union to marriage and make your marriage date retroactive to the date of the civil union. When applying for a Special Enrollment Period, be sure to use the date your civil union was converted to a marriage (the later date) rather than the retroactive marriage date. Also, you must agree to file taxes jointly to be eligible for financial help on the Marketplace. • Please visit GetCoveredIllinois.gov for more information on marriage equality and the ACA.

8. Coverage Start Dates • The date your coverage begins depends on the life event you experienced and the day you select your plan. If you experienced a Qualifying Life Event, please refer to the chart below to see when your coverage will start.

9. What is a Complex Issue? • Complex issues are issues beyond your control that kept you from enrolling in coverage before the March 31 deadline and may qualify you for an SEP. • This is the second reason (besides a QLE) that a person can still enroll after Open Enrollment.

10. Examples of Complex Issues • Delayed Medicaid Denials: You applied during Open Enrollment, but were found ineligible for Medicaid or All Kids after March 31. • System errors related to immigration status: technical problems resulted in an incorrect eligibility result for you based on your immigration status. • Eligible and current COBRA beneficiaries: If you are eligible for COBRA or are a COBRA beneficiary, you can apply and select a plan through July 1, 2014.

11. Examples of Complex Issues • AmeriCorps, VISTA, or National Civilian Community Corps Members: If you are an AmeriCorps, VISTA, or National Civilian Community Corps member, you will have 60 days to from the date you begin or end your service to enroll in a Marketplace plan. • Pre-Existing Condition Insurance Plan (PCIP) Enrollees: You will have until June 30, 2014, to select a Marketplace plan. • Exceptional circumstances: You faced exceptional circumstances that stopped you from finishing your enrollment on time, such as a natural disaster or medical emergency. • Enrollment errors: You enrolled through the Marketplace, but the insurance company did not get your information due to technical issues.

12. Examples of Complex Issues • Misinformation, Misrepresentation, or Inaction: Misconduct by an individual or organization that provided you with formal enrollment assistance resulted in a failure to enroll you in a plan, enrollment in the wrong plan against your wish, or no offer of financial help even through you were eligible for it. • Federal Marketplace display errors: Healthcare.gov displayed incorrect information to you about plans when you selected a plan, such as incorrect benefits or your share of costs. • Error messages: Error messages on healthcare.gov prevented you from completing enrollment. • Unresolved casework: A federal caseworker is still working with you to fix your enrollment issues. • Other system errors: Other issues that delayed enrollment, as determined by the federal Marketplace.

13. How do I finish my enrollment in Marketplace coverage if I have a Complex Issue? • If you have experienced a complex issue and need an SEP to complete your enrollment, contact the federal Marketplace Call Center at 1-800-318-2596 (TTY 1-855-889-4325). The Marketplace Call Center may be able to give you an SEP. • Exception: delayed Medicaid denial (can go directly to healthcare.gov) • If the Marketplace Call Center cannot approve an SEP based on the phone call, your case will be forwarded to a federal caseworker. If the caseworker approves an SEP, you will need to call the Marketplace Call Center back to start the SEP and enroll in coverage.

14. Complex Issue SEP Start Dates • After following the guidelines for issuing an SEP described on previous slides, in most cases, consumers will have 60 days to select a plan from the date they are granted the SEP, which could be one of the following “triggering events”: • The date that the consumer receives a letter informing them that they are eligible for an SEP; • The date that the consumer contacts the Call Center and is found eligible for an SEP; OR • The date that the caseworker finds an individual eligible for an SEP • While the state can provide information on SEPs, the federal government must approve your SEP.

15. Coverage Start Dates • For Complex Issue SEPs, coverage start dates will generally follow the regular effective dates below, but in some instances, the coverage effective date will be the date of the triggering event. Be sure to ask the federal Marketplace call center representative or check your Eligibility Notice to see when your coverage will begin. • Consumers who select a plan between the 1st and 15th of the month will have coverage effective the first of the following month. • Consumers who select a plan between the 16th and the end of the month will have coverage effective the second following month.

16. Do I qualify for an SEP in the Marketplace if my Medicaid application was denied? • If the Medicaid application you submitted during Open Enrollment, before March 31st, was denied because you had too much income or did not meet other eligibility requirements, you can still get health coverage on the federal Marketplace through a 60-day Special Enrollment Period. This is because you applied during the open enrollment period and you were “in line” waiting for your application to be processed.

17. What if I think I qualify for a Special Enrollment Period but the Marketplace does not agree? • If your SEP is denied by the Marketplace and you don’t agree with the decision, you can file an appeal. If the Marketplace decides you qualify for an SEP based on your appeal, you can get coverage back to the date your SEP was first denied. • To file an appeal: • Download the Illinois appeal form at GetCoveredIllinois.gov and follow the instructions • Mail your appeal to: Health Insurance Marketplace 465 Industrial Blvd. London, KY 40750-0061 • When possible, include a copy of any eligibility determination notice or other official notice you received. This isn’t required but will help the Marketplace process your appeal. • Navigators can also help you file an appeal for free • You can also appoint an authorized representative to help you. Your representative can be a family member, friend, advocate, attorney or someone else who will act for you.

18. Do I need a Special Enrollment Period to Enroll in Medicaid? • No. Medicaid and All Kids enrollment is year round. • Take the first step at GetCoveredIllinois.gov and answer a few questions to find out whether you could qualify. Both Medicaid and insurance through the federal Marketplace will provide comprehensive coverage.

19. Do I need an SEP to enroll in the Small Business Health Options Program (SHOP) Marketplace? • No, federal SHOP Marketplace enrollment is open year-round. • The federal SHOP Marketplace is open to employers with 50 or fewer full-time equivalent employees (FTEs). If you have fewer than 25 employees, you may qualify for tax credits if you buy insurance through SHOP. Visit https://www.healthcare.gov/marketplace/shop/ to get started.