Lesson 4 of 8
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Enrollment and Qualification for Healthcare.gov

Collin Gabriel November 30, 2021

Marina Cassandra (00:00):

So in order to enroll, uh, usually on market or off market, there are special, there are specific enrollment periods. And before the American rescue plan open enrollment was typically November 1st through December 15th in order to have coverage starting January 1st. However, this year we have an extension of the open enrollment period through January 15th. If you enroll before December 50, so you could actually apply the 1st of November that you must choose the plan and enroll by the 15th of December to have it, um, effective the first of the following month, if you choose to enroll after the 15th of December, but before the 15th of January, your coverage will start February 1st, also during special enrollment periods, um, in many cases for different types of qualifying life events, um, you will have that 15th of the month is going to be your cutoff in most cases. Now, if you’re, if the reason that you’re qualifying for special enrollment period is the loss of coverage, then anytime that you apply with you would get it the first of the month, as long as it’s.

Marina Cassandra (01:16):

So let’s say, um, you found out that, um, you were getting laid off and you were going to have no coverage at the end of the month. You could hop onto healthcare.gov and, and it’s the 20th of the month, but I just found out I’m only 10 more days on this job. You can apply for a special enrollment period and still get the first of the next month so that you don’t have a gap in coverage. So that’s an exception to most of these qualifying life of that. So if you know, um, within 30, within 60 days of, uh, any of these qualifying events, either 60 days before, 60 days after you can, um, apply for a special enrollment period through healthcare.gov qualifying life events. So if you add a child to your household through adoption, foster care or birth, and that is a qualifying life event, and the coverage would begin for that child on the date of that adoption birth or placement in care so that it could be retroactively effective back to that date, another qualifying life event.

Marina Cassandra (02:28):

Again, it’s the loss of coverage. So if you’ve lost your coverage, you can apply up to 60 days before or after. And it’s 60 days before you’ve lost your coverage. Then your coverage, your new coverage would start on the first of the month after your coverage. And now if you do it 60 days after you’ve lost your coverage, I don’t think it’ll go retroactive. So it’s really important to be proactive and trying to avoid a wa a lapse in coverage or gap in coverage. Another qualifying life event is aging out of your parents’ plan or aging out of a plan. Uh, perhaps you were, um, covered by Oregon health plan. You turn 19. And because of that, you are now in a different, um, federal poverty level eligibility level, basically. So, um, now you can look at a marketplace plan because you’re losing coverage because you’ve aged out, or if you’ve aged out because you were on a parent’s plan and you’ve turned 27.

Marina Cassandra (03:34):

Another way that you can qualify for special enrollment period is if you become a new citizen in the United States or a new citizen as a federally recognized tribe, um, also if your immigration status changes, so let’s say, um, you’re here on a visa and then you become a lawful permanent resident. But at this time a lawful permanent resident, even if their income qualifies, they’re not qualified to get Medicaid. And so they could shop on the marketplace because they’re now waffle permanent residents, but they’re not allowed to get Medicaid so they can shop on the marketplace. And then there’s a five-year ban, which is going to, is going to change with some new laws coming in in Oregon. That there’s a five-year ban on lawful permanent residents accessing Medicaid. So when that five-year ban is up, then they should definitely reapply to see if they qualify for Medicaid or marketplace coverage. Another thing that could cause a special moment or qualifying life event is when your income increases or decreases significantly, you always want to, um, if you haven’t a significant increase or decrease, you want to update your income on your healthcare.gov applications, because it could be that you qualify for more or less tax credit towards your premium, or it could be that you qualify for Medicaid. So that can trigger a qualify or qualifying life event and special enrollment periods.

Duane Lane (05:05):

And I had a question regarding, excuse me, I had a question regarding the, um, a lot of the entrepreneurs business owners that I work with specifically are like farmers or have seasonal income, um, that fluctuates what kind of percentage or, um, what is the recommended idea or philosophy regarding them reapplying or updating their income? So like a farmer, you know, obviously in where we live in the Northwest, their income can fluctuate from like April, may until October, but then in the non-growing season, it’ll decrease tremendously or again,

Marina Cassandra (05:51):

That’s a great question

Duane Lane (05:51):

or again for somebody who owns like a retail location, seasonal income might grow during the holiday season. So what, what, what recommendations or advice would you have for that, or,

Marina Cassandra (06:04):

Well, depending on what their income level is, they could either, um, apply during the low month for Medicaid or, um, since it is an annual income that you report on your healthcare.gov application, you estimate what your annual income will be, even though you might have some months that are higher than others, and then it will, it will base eligibility. Um, that now if you have a significant increase, I would say more than 10%, um, you know, of an increase that you didn’t account for, maybe you’re making much less than you anticipated, or maybe you’re having a great year. And, uh, you know, you’re Jeff Bezos and we just really, um, you know, capitalizing off the current climate. Um, then you definitely want to go back in, update your income and see if that changes your eligibility for tax credits or cost sharing. I would say 10%, I think for, for Medicaid, sometimes they say an increase of a hundred dollars could make a difference.

Duane Lane (07:07):


Marina Cassandra (07:07):

So it really depends on, on where they think they’re going to fall in those eligibility brackets.

Duane Lane (07:13):

Yeah. Wonderful. That makes a lot of sense, especially with our economic times with regarding the COVID right now.

Marina Cassandra (07:22):

Exactly. There’s so much uncertainty, you bet. And that’s part of why the American rescue plan did made so many changes this year, um, to increase affordability. So the tax credits are, um, more available to more people. The eligibility, uh, level are, um, you can, you can make more money and get more assistance than you could last year. And for folks who were on, who received at least one week of unemployment in 2021, they were able to have the maximum tax credits and maximum cost sharing reductions when they applied this year. So some folks got a plan for their whole family for a dollar because of that. Now, unfortunately, that is coming to an end at the end of the year. So, um, any folks who were able to benefit from that this year definitely want to go in and update their applications. So they don’t get sticker shock and auto renewed into a plan where they have much less assistance.

Marina Cassandra (08:24):

Okay. So w we were just talking about financial changes. Uh, another change that could qualify you for a special enrollment period would be moving, um, a couple of reasons for that, even if you’re moving within the state, different plans are offered in different counties and geographic locations. So if you are moving, if you are new to Oregon, if you’ve just moved to Oregon, that would be a special enrollment period. If you’ve moved here from another state, again, in order to, um, shop on Oregon healthcare.gov through Oregon, you need to be an Oregon resident. Uh, you might change counties or zip codes, and that might give different not only different plans, selections in those areas, but because tax credits are based partly on, uh, geographic locations and what’s supposed to be affordable for that area. It could change your tax credits as well. So if you’re moving, if you’re changing zip codes, I mean, you want to update your address anyways, so they can follow you around with notices, but you also want to make sure that you were in the correct, um, county and zip code.

Marina Cassandra (09:33):

I had a really difficult case come across my desk, where there was a woman who, um, rented a house near OHS while her husband was dying and she wanted to be close to her husband. Well, that changed her eligibility. And she wound up not being covered for tens of thousands of dollars, um, that she was responsible for because she didn’t update her address soon enough. And then when they found out that she was living there, they said, oh, well, that’s not even in the coverage area. So we want to be really, really careful to update. Um, we were able to, you know, we were able to work things out in this situation. Um, you know, we lifted all the fine print and we’re able to pull something out of the hat for her, but it was a very stressful thing for her to go through.

Marina Cassandra (10:25):

Um, you know, she just lost her husband and now she’s got all these bills to wasn’t expecting. So, yeah. Um, so, so moving is very important and updating address is very important. It may or may not qualify you for a special moment period, but you know, you just log on and update your application to find out. Also if a person is incarcerated, um, if, if a person is leaving incarceration, that’s kind of like moving to Oregon in some respects, you know, that, um, you’re now out in Oregon and you can qualify for special enrollment that way the marriage qualifying life event is a little bit different because at least one of the members of the couple, when one of them has to have had minimum essential coverage before they got married. So basically if you’ve got two people with no coverage at all, and they get married, so they can hit coverage, they can get a special enrollment periods.

Marina Cassandra (11:26):

That’s really not going to work unless one of them already had coverage and one, or both of them had coverage. And that goes to, yeah, that’s really a distinct difference. Um, and then, you know, some of these are going to have different, effective dates too, based on. So I think, um, marriage is the first of the month following their wedding. I’m not sure if it goes back to the date of the wedding, but if that marriage involves new dependents, you’ve got some new step kids, um, they can get on. And as long as one of them had coverage before that, okay. So the last one that we’re going to cover is the opposite of the first one is when your household gets smaller, because someone has passed away or divorced or moved to, you know, college got married or whatever. So when your household gets smaller, your taxable household gets smaller. That will also change eligibility. And so anything that could change as eligibility is, uh, typically a qualifying life event for special molded period.

Duane Lane (12:37):

And then in case, uh, a divorce do both parties get the option. Is it a special enrollment for both parties?

Marina Cassandra (12:46):

Yes, it should be because here’s the thing when you are, um, when you’re a house or when you’re a couple or families, couple of have to file jointly to get that tax credit. And so now that they’re no longer going to be filing jointly, they can each apply on their own with their own income once they’re separated. And once they’re getting a divorce, now, if they were married most of the year and they just, you know, when they go to reconcile their taxes, they can, um, you know, they can deal with that at that time, if they want to just continue the same coverage. And I’m not sure how that’s going to work with reconciling taxas, they want to consult a tax expert that basically, um, you know, if you get divorced, you have that option to have a special enrollment period and qualify for your own financial assistance. So if you’re a stock, that’s making a lot less money, you might get a lot more tax credits. And conversely, if you were married to someone who made less money, now, it’s all based on you and your income, and you might have fewer tax credits

Duane Lane (13:44):

I understand, thank you.

Marina Cassandra (13:48):

You’re welcome.

Marina Cassandra (13:50):

So here we go, who can shop on healthcare.gov? First, you must live in the United States. You must live in a state that’s served by healthcare.gov, Oregon healthcare.gov. The Oregon health insurance marketplace is actually the state-based partner to healthcare.gov. Healthcare.gov is a federal platform that we use for eligibility and enrollment. Some states have their own exchanges or marketplaces such as Washington’s plan finder and California’s covered California. Those exchanges you’d have to live in their states. And you could use, so if you’d say, if you live in Washington, you use your state’s exchange. If you live in California, you use a California exchange. And in Oregon, we use healthcare.gov. In order to do that, you must live in United States and in Oregon. You must not be incarcerated unless you have not been adjudicated. So if you haven’t been convicted, you, you’re waiting your day in court. You can still keep your coverage or apply for coverage.

Marina Cassandra (14:57):

That is different from the Oregon Health Plan, however, where you cannot access Medicaid at this time while you are, um, while you are detained. However, I know there’s legislation, that’s hoping to change that. So stay tuned for, you know, how those things change in the Oregon legislature. You also have to have an eligible immigration status. Now here’s the good news for the marketplace. Anyone with a lawful, with lawful residence can shop on the marketplace, except for those with undocumented immigration and those with DACA status or deferred action for childhood arrivals. So that means that there are some folks who cannot apply for Medicaid, but they’re lawfully present. And even though their income might qualify them for Oregon Health Plan, they’re out their immigration status doesn’t, but they can apply at healthcare.gov and receive really great tax credits if their income is low enough for OHP, but they don’t qualify because of their immigration status.