PPACA Update:
"Open Enrollment" is over - now what?






PPACA "Open Enrollment" has ended for families and individuals responsible for purchasing their own health insurance.  For those individuals, the next opportunity to enroll in a qualified individual health insurance plan (QHIP) will be the 2014 open enrollment period this coming November (2014) for a January 1st, 2015 effective date.  Throughout the 2014 calendar year, you may be eligible to enroll in a QHIP if you have meet one of the following criteria:


Satisfaction of a health insurance "Qualifying Event"


"Qualifying Events" are events that will allow you to enroll in an qualified individual health insurance plan after "Open Enrollment" ends.  Qualifying Events include, but are not limited to, the following:


  • Loss of coverage from your employer or spouse's employer
  • Going from "Full Time" employment with employer sponsored coverage down to "Part Time" employment and loosing employer sponsored coverage
  • Loss of coverage through a divorce
  • Gaining spousal eligibility through marriage
  • Enrollment of a newborn child
  • Moving from one state to another state


If you satisfy any of the "Qualifying Events" listed above you may qualify to enroll in a  QHIP throughout the year.  Please keep in mind that we are simplifying this topic and each individual situation is different.  The best way to determine your eligibility for certain is to contact a licensed, marketplace certified Benefit Advisor at Altruis Benefit Consulting.  We will review your personal situation, reference the new regulations, and prepare a strategy to facilitate the change in coverage




Satisfaction of a "Limited Circumstance Special Enrollment Period"


Over the course of the first "Open Enrollment" for PPACA, everyone can agree that the Health Insurance Marketplace (HIM) left much to be desired from a functional perspective.  As a result of these functional challenges, CMS has decided to extent "Open Enrollment" through 4/15/2014 for those individuals who have experience technical issues prior to 03/31/2014 which were not resolved in time to enroll in a plan.


That being said, if a consumer experiences any of the following issues, the HIM may be able to provide a Special Enrollment Period (SEP) allowing the consumer to enroll in coverage through the Marketplace.  


 Limited Circumstance SEPDescriptionExamples 
 Exceptional CircumstancesA consumer faces exceptional circumstances as determine by CMS, such as a natural disaster, medical emergency, and planned system outages that occur on or around plan selection deadlines A natural disaster, such as a  an earthquake, massive flooding, or hurricane

A serious medical condition, such as an unexpected hospitalization, or a temporary cognitive disorder

A planned HIM system outage, such as SSA  system outage
MIsinformation, Misrepresentation, or Inaction
 Misconduct by individuals or entities providing formal enrollment assistance (i.e. insurance carrier, navigator, or certified benefit advisor) resulting in one of the following:
A failure to enroll the consumer in a plan
Consumers being enrolled in the wrong plan against their wishes
The consumer did not receive "advanced premium tax credits" or "cost sharing reductions" for which they were eligible
Representative enrolled a consumer in a plan that the consumer did not want to enroll in 
 Enrollment ErrorConsumers enrolled though the Marketplace, but the insurance company didn't get their information due to technical issues consumer's information is received by the insurance carrier and may be processed, but the enrollment file contains defective or missing data. 
System errors related to immigration status
An error in the processing of applications submitted by immigrants caused the consumer to get an incorrect eligibility result when they tried to apply for coverage
Immigrants with income under 100% of the poverty line are eligible for premium tax credits and cost-sharing reductions did not receive the proper determination 
Display errors on HIM website
Incorrect plan data was displayed at the time the consumer selected the QHIP, such as a plan benefit and cost-sharing information 
Data errors on premiums,   benefits, copay, or deductibles 
Medicaid/CHIP Marketplace transfer 
Consumers who were found ineligible for Medicaid or CHIP and their applications weren't transferred between the State Medicaid or CHIP agency and the Marketplace in time for the consumer to select a plan during open enrollmentConsumers, who applied at through the HIM, were assessed eligible for Medicaid or CHIP, were found ineligible for Medicaid or CHIP by the state agency and then weren't transferred back in time for an HIM determination during open enrollment 
Error Messages
A consumer is not able to complete enrollment due to error messages Error or box screen indicating that the data sources were down and they could not proceed with enrollment 
Unresolved caseworkA consumer is working with a caseworker on an enrollment issue that is not resolved prior to March 31st.Consumers who began the case work process but it was not resolved prior to the end of Open Enrollment
Victims of domestic abuseA consumer who is married, and is a victim of domestic abuse.  Consumers who are in this category can apply and select a plan through May 31st, 2014Prior to clarifying guidance from Treasure and HHS, consumer assumed or was informed that APTC were unavailable to consumers who are married and not filing a joint tax return.  Consumer may or may not have attempted to apply 
 Other system errorsOther system errors, as determined by CMS, which hindered enrollment completion  



There are specific processes to initiate a Limited Circumstance SEP and the licensed, insured, and HIM certified benefit advisors at Altruis Benefit Consulting are extensively trained on how to execute them.  If you believe that you may qualify for one of these Special Enrollment Periods please contact us to learn more!
877.44.ALTRUIS (877.442.5878)
Kind Regards,
Anthony P Fracchia
Altruis Benefit Consulting





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