Special Enrollment Period for Consumers Denied Medicaid/CHIP After Previous 60 Day SEP Window Expires

KEY TAKEAWAY: A special enrollment period is now available for consumers who apply for Marketplace coverage due to a qualifying life event, are assessed by the Marketplace as potentially eligible for Medicaid or CHIP, and are then determined ineligible for Medicaid/CHIP after their previous 60 day window to enroll in coverage has expired. To access this SEP, consumers must call the Marketplace Call Center; they cannot currently access it through the online application.

CMS has made a special enrollment period (SEP) available to consumers who are otherwise eligible for Marketplace coverage and experience both of the following:

  1. Apply for coverage through the Marketplace due to a qualifying life event and are assessed by the Marketplace as potentially eligible for Medicaid or the Children’s Health Insurance Program (CHIP)
  2. Are then determined ineligible for Medicaid/CHIP by their state Medicaid/CHIP agency after their original SEP’s 60 day window has expired.

In order to access this SEP, consumers must call the Marketplace Call Center at 1-800-318-2596 (TTY: 1-855-889-4325). Consumers cannot currently access this SEP through the online application. Consumers who qualify for this SEP will receive a retroactive coverage effective date back to the date they would have been enrolled in a QHP if they’d originally been determined eligible for Marketplace coverage.

Remember that consumers who elect a retroactive coverage effective date must pay the premiums due for all months of coverage back to their retroactive coverage effective date within one billing cycle or the timeframe established by their state. If applicable, APTC and CSRs will be recalculated for the enrollment group, and the resulting amounts will align with the original coverage effective date. Any claims for services received by the newly insured individual back to the retroactive coverage effective date, will need to be submitted to the issuer and will be refunded for covered services minus copays.

  • Example: Nick, his wife Sarah, and their daughter Maddy had health coverage through Nick’s employer until Nick lost his job. Because they lost minimum essential coverage (MEC), Nick and his family were eligible for an SEP to enroll in coverage through the Marketplace. They had 60 days to select a plan. They applied the month after losing coverage, and the Marketplace determined that Nick and Sarah were eligible for a QHP with APTC/CSRs. The Marketplace assessed Maddy as eligible for CHIP and sent her application to the state CHIP agency for a final determination. Nick and Sarah enrolled in a QHP, and a month and a half later the state CHIP agency denied Maddy’s application. By the time Maddy received her CHIP denial notice, the initial 60-day window for her to select a QHP along with her parents under the original loss of MEC SEP had expired. Maddy is eligible for this new SEP so that she can be added to her parents’ plan, and she must access this SEP through the Marketplace Call Center.

Please note: A consumer may also be eligible for a special enrollment period if he or she:

  • Applied for coverage through the Marketplace during the 2015 open enrollment period that ended on February 15, 2015; and
  • was assessed potentially eligible for Medicaid/CHIP coverage by the Marketplace; and
  • was determined ineligible for Medicaid/CHIP coverage by their state Medicaid/CHIP agency after February 15, 2015.

NEW: Consumers can Cancel Their Marketplace Dental Plans by calling the Marketplace Call Center or their Dental Plan Issuer Directly

KEY TAKEAWAY: Consumers can now end their Marketplace dental coverage without also terminating their Marketplace health plans by calling the Marketplace Call Center or by contacting their dental issuer directly. Assisters can help consumers understand this newly-available method of canceling Marketplace dental coverage; they should also make sure that consumers understand that consumers who terminate their dental coverage outside of Open Enrollment and want to enroll in a different dental plan through the Marketplace will need to wait until the next Marketplace Open Enrollment Period unless they qualify for a special enrollment period.

Consumers can now end their dental coverage while still retaining their QHP prior to the Marketplace Annual Open Enrollment Period. As of June 1, 2015, consumers who are enrolled in both a qualified health plan (QHP) and a qualified dental plan (QDP) can terminate their dental coverage while keeping their QHP coverage. Consumers can do this either by calling the Marketplace Call Center at 1-800-318-2596 (TTY: 1-855-889-4325) or by contacting their dental issuer directly. Note that some dental issuers may request that consumers contact the Marketplace Call Center in order to terminate their dental coverage. Consumers who are enrolled in both a QHP and QDP cannot terminate just their dental coverage online at HealthCare.gov at this time. They can only do so through the Marketplace Call Center or by contacting their dental issuer directly. Consumers should keep in mind that if they terminate their dental coverage now and want to enroll in a different dental plan through the Marketplace, they will need to wait until the next Marketplace Open Enrollment Period, unless they qualify for a special enrollment period.

 

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