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Transitioning from MC to CovCA during Special Enrollment Periods
The discontinuance of MAGI MC is considered a loss of Minimum Essential Coverage (MEC) which is a Qualifying Life Event (QLE) in Covered CA that creates a Special Enrollment Period (SEP), and coverage can begin the month following the final MC eligibility determination if the client picks a Qualified Health Plan (QHP) and pays his/her APTC premium timely.
Qualifying Life Events
The following life events or situations qualify clients for SEPs in Covered CA and allow a client to enroll or change plans outside of Covered CA’s Open Enrollment periods:
• Lost or will soon lose their MC eligibility or other health insurance (also known as loss of MEC).
• Permanently moved to/within CA.
• Had a baby or adopted a child.
• Got married or entered into a domestic partnership.
• Domestic violence survivors. (If married, abuser’s income not counted if survivor lives apart and is unable to file joint tax return.)
• Returned from active military duty service.
• Released from jail or prison.
• Gained citizenship/lawful presence. • Federally recognized American Indian/Alaskan Native.
• Loss of Medically Needy SOC Coverage (only once per calendar year).
• Other qualifying events as identified in CalHEERS.
• New App-based driver.
Clients have up to 60 days after the QLE to enroll in or change their Covered CA plan. Most of these SEPs are subject to the 15th day of the month rule in determining the start date of coverage. The 15th day of the month rule pertains to the deadline in which clients eligible for Covered CA must select a QHP to have coverage become effective on the first day of the following month. However, there are some exceptions.
The following situations qualify as exceptions to the 15th day of the month rule for Covered CA enrollment and can start coverage on an earlier date:
Loss of Minimum Essential Coverage
If a client loses full-scope or pregnancy MC coverage, job-based coverage or other MEC such as Medi-Cal Access Program (MCAP) or Children’s California Health Insurance Program (CCHIP), and they are otherwise eligible for Covered CA, the start date of the Covered CA health plan coverage can be as early as the first of the month following the month in which a client’s MC or other MEC is discontinued. However, the client must select a plan and make the premium payment timely for this immediate coverage start date to happen.
CalHEERS is already programmed with the functionality to bypass the 15th day of the month rule for loss of MEC as well as to add the correct effective begin date when this QLE is identified in CalHEERS and/or CalSAWS. A loss of MEC can be reported up to 60 days before or after the life event date. Refer to the following Covered CA Job Aids: Special Enrollment Administrative Review and Special Enrollment for instructions on how to process a SEP case with a loss of MEC in CalHEERS.
Marriage or Entry into Domestic Partnership
If an individual gets married or enters into a domestic partnership, the Covered CA health plan coverage can start on the first day of the next month following plan selection and premium payment regardless of when the individual makes the plan selection during that month. A life event of marriage or domestic partnership can only be reported the day of, or any day after but not exceeding 60 days from the life event date.
Birth or Adoption or Foster Care
If a child is born or a client adopts a child or a foster care child is placed in the client’s custody, the Covered CA health plan coverage can start on the date of the birth of the child, adoption, or the placement of the foster care child or the first of the month following the event based on the client’s choice.
New App-based driver
If an individual is an app-based driver their network company is required to provide healthcare subsidies (stipends) on a quarterly basis. The amount of these subsidies are based on their weekly “engaged time driving” per quarter. Payments will be made 15 days after each quarter to the individual. These payments are counted as income for the purposes of eligibility for the federal Premium Tax Credit, Cost Sharing Reductions and California Premium Subsidy.
Avoiding a Gap in Coverage
When a client transitions from MC (or other CPPs) to Covered CA and the client requests assistance with Covered CA enrollment process and plan selection, then the EW must assist the client with their Covered CA health plan selection to the fullest extent possible. EWs should also inform the client to make a timely premium payment to avoid a gap in coverage. Transitioning clients must select a QHP in the same month as the MC discontinuance date to have their Covered CA health plan start the following month and avoid a gap in coverage. Outside of the Covered CA Open Enrollment periods, when clients have a loss of MEC or other QLE, they have up to 60 days before and after the date of the QLE to enroll in a Covered CA health plan or change their existing Covered CA coverage.
In the example directly above, if the client selects a Covered CA health plan on or before June 30, 2016 and then pays the premium timely, his/her healthcare coverage will begin on July 1, 2016 and the client will not have a gap in coverage. However, if the client does not pick a plan until after June 30, 2016, the Covered CA health plan coverage will not begin until August 1 or later (depending on when the plan is picked and the payment is made). For example, if the client does not pick a plan until after July 31, 2016 but before August 29, 2016, and then pays before the billing due date, the Covered CA health plan will not begin until September 1, 2016. Covered CA does not offer retroactive start dates of coverage when a client has a loss of MEC.
Loss of Medically Needy Share of Cost Coverage
Clients with SOC MC and no other healthcare coverage can meet the requirements for an SEP if they meet their MC SOC in at least one of the two previous months. These clients are entitled to this SEP once per calendar year. Clients who meet their SOC in a particular month can be evaluated for eligibility through Covered CA (including APTC/CSR) based on an SEP in the following two months. Clients meeting their MC SOC in one month and having to meet it again the following month is considered loss of medically needy SOC coverage at the end of that month. When clients contact Covered CA through the Service Center, Service Center Representatives (SCRs) will direct current MC clients to the county for assistance. If the client is currently eligible for SOC MC and wants to enroll in an APTC plan outside the open enrollment period, an EW must determine whether or not the client meets the requirements for any possible SEP reason (including the loss of medically needy SOC coverage). If the client has met his/her SOC in at least one of the two previous months, he/she is eligible for an SEP for the loss of medically needy SOC coverage. EWs should make every reasonable effort to verify that the client has certified his/her SOC or has lost eligibility for a medically needy SOC program. Clients “certify” or meet their SOC when they either incur necessary medical expenses or pay medical costs that meet or exceed their SOC amount. If the MEDS Online Provider Inquiry or SOC Case Make-up Inquiry Request show the SOC was certified in one of the two previous months, the EW can evaluate the client for APTC eligibility. If these electronic sources show that the SOC was not certified in one of the two previous months, the EW can accept the client’s attestation that the SOC was certified in one of the two previous months, and document it in the Journal Detail page before evaluating for APTC eligibility.
When processing the SEP in CalSAWS, the SEP reason would be “loss of MEC” and the date of the “loss of MEC” is the last day of the most recent month in which the client’s SOC was certified and medically needy SOC coverage was lost. If the client is eligible for APTC, he/she will have up to 60 days from the date of loss of medically needy coverage to choose and enroll in a QHP. If the client requests assistance with plan selection, then the EW should assist the client to the fullest extent possible. The Covered CA health plan coverage will be effective as of the first of the month following plan selection and timely premium payment. The EW should also inform the client that he/she has the option to keep both SOC MC and QHP coverage.
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