What’s So Special About Special Enrollment?

What’s So Special About Special Enrollment?

Health insurance is something we all need, but signing up for it can sometimes be a challenge. Hispanic Federation is here to help. Open enrollment for receiving health care through the Affordable Act is actually now closed, but did you know you might be eligible to sign up under a “special enrollment” period if you meet certain requirements?

If you have experienced what is known as a “qualifying life event,” you might be eligible to receive coverage even thought the open enrollment deadline has passed.

We sat down with our Senior Director of Health Operations, Lilliana Melgar, to find out answers to five of the most frequently asked questions about the special enrollment period. If you meet any of the requirements, please contact Liliana Melgar today for assistance or to answer more of your questions.

Q1: What is special enrollment and how is it different from the regular “open enrollment” period?

 Melgar: An Open Enrollment Period is a limited time of year – usually November through January in New York – when you can enroll in a Qualified Health Plan. If you do not enroll during this time, you will need to wait until the next enrollment period. However, there are some exceptions. You may be able to enroll in a Qualified Health Plan outside the Open Enrollment Period if you are eligible for a Special Enrollment Period.

 A Special Enrollment Period is when someone has a special life event (called a “Qualifying Life Event”) that makes it possible for them to enroll in or change their coverage through a Qualified Health Plan and is outside of the “Open Enrollment Period.”

 When you can enroll depends on your program eligibility. This is based on age, income and several other factors. Please note: enrollment is open all year if you are eligible for:

  • Medicaid

  • Child Health Plus

  • Essential Plan

 American Indians and Alaskan Natives can enroll in a Marketplace health insurance plan ANYTIME DURING THE YEAR, not just during the yearly Open Enrollment Period

Q2: How do I know if I’m eligible for special enrollment?

 Melgar: There are a number of factors that might make you eligible:

  • Loss of health insurance (for reasons other than you did not pay your premium)

  • If you’re in New York state: A permanent move to or a move within the State that makes new health plans available to you (you must have had other coverage within the past 60 days) 

  • Marriage or domestic partnership (you must have had other coverage within the past 60 days)

  • Divorce or legal separation

  • Pregnancy certified by a health care practitioner

  • Birth or adoption of a child, or placement of a child in foster care

  • Becoming eligible or ineligible for help paying for your Qualified Health Plan coverage

  • Becoming a citizen, national or lawfully present individual. Generally you must report a Qualifying Life Event to NY State of Health within 60 days.

You may need to provide proof of the Qualifying Life Event to your new health plan or to New York State of Health.

Q3: Am I required by law to have health insurance?

Melgar: For plan years through 2018, if you can afford health insurance but choose not to buy it, you may pay a fee called the individual Shared Responsibility Payment. (The fee is sometimes called the "penalty," "fine," or "individual mandate.")

Starting with the 2019 plan year (for which you’ll file taxes in April 2020), the Shared Responsibility Payment no longer applies.

Currently for the 2019 plan year, the Shared Responsibility Payment (“mandate,” “penalty”) no longer applies. You don't need an exemption for 2019 or beyond.

 Q4: Is there assistance available for enrollment? For paying premiums?

Melgar: Yes. Some individuals may be eligible to receive assistance paying for monthly premiums. (MONTHLY PREMIUMS: The price you pay each month will depend on the plan you pick. Many people are eligible for tax credits which lower your monthly cost. Individuals earning up $48,560 a year and a family of 4 earning up to $100,400 may be eligible for tax credits.)

In addition, some people may be eligible for assistance paying for the cost sharing. (COST SHARING: Cost sharing is the amount you pay when you get a health care service. Some people are also eligible to get help paying for these costs, based on their income. Below are examples of the QHP cost sharing level for standard plans offered at four levels. Other plans are available with different cost sharing and additional covered services.)

Q5: If I’m eligible for special enrollment, how do I get started?

Melgar: Please contact me, Liliana Melgar, Senior Director of Health Operations: lmelgar@hispanicfederation.org  212-233-8955 ext. 127

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