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Covered California and Obamacare related questions from consumers, employers and agents are answered by Phil Daigle with the best information available at the time. Archived entries may no longer be accurate as the Covered California and Obamacare knowledge-base is evolving quickly. TO REQUEST A PERSONAL RESPONSE INCLUDE EMAIL ADDRESS.


Life Triggering Event?

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Question: In final disclosure when purchasing plan, it states that I can’t change plans unless a life triggering event occurs. Does this mean I am wedded to this plan forever or just for the year. Also, what constitutes a “life triggering event”?

Answer: I believe you are referring to a “qualifying event”. Conception would be a “life triggering” event. Just kidding. There are certain qualifying events that must be met in order to be eligible for special enrollment (outside open enrollment) in Covered California. The length of the special enrollment window is 60 days after the qualifying event. If you do not meet one of these qualifying events, you must wait until the next open enrollment period. Here is a list of qualifying events that will trigger (there’s that word) a special enrollment.

  • Lose Minimum Essential Coverage;
  • Gain a dependent or become a dependent;
  • Become a U.S. citizen, U.S. national or lawfully present
  • Cancellation or lapse of coverage in a Covered California is unintentional, inadvertent, or erroneous as a result of an error, misrepresentation, or inaction of Covered California or Health and Human Services.
  • Covered California substantially violated a material provision of its contract in relation to the enrollee.
  • Become newly eligible or newly ineligible for advanced premium tax credit (subsidy) or has a change in eligibility
  • Employer-sponsored plan will no longer be affordable or provide minimum value.
  • A permanent move
  • Recently released from incarceration.

21 Comments

Mike …

The PPACA does not make you a slave to your employer. If you change employment and it causes a loss of health insurance, you have had a “qualifying event” and may enroll in a health plan on- or off-exchange.

‘life triggering’, ‘qualifying event’ - mind you i’ve searched this out a bit and i don’t see where voluntarily changing jobs (e.g. from a full time employee to a contractor) qualifies as this event. meaning that i am, defacto, a indentured servant until the next open enrollment (assuming that the position will remain open until next spring). this is accurate?

A Benefits Identification Card is what persons who have Medi-Cal coverage receive. I don’t know why you have received that if you are not eligible for Medi-Cal. To communicate with me privately, click on my name to be taken to my website, where you will find my phone numbers and email address.

Max,

I have enrolled in Blue Shield PPO 80 through CC with the operator help. I can see that in the CC website system that I am enrolled in this plan. In the meantime is impossible to contact by phone Blue Shield to get a confirmation. More then two hours waiting on the phone still no operator. And I’ve got home a Benefits Identification Card ! Could this card be for Cost Sharing Plan or they just thrown me into Medi-Cal? (Officially I am conditionally eligible and need to submit income docs by March 10 according with CC web account but who knows what is going on…)

Dan wrote: “So they are stuck with this idea that if your income is low NOW you MUST take Medical although I can earn later a million dollars!”

Dan, don’t misunderstand. Covered California is not making the rules, they are forced to play by them. The PPACA says that if a person is eligible for Medi-Cal he is ineligible for tax credits.

Your only alternative is to post any amount of income that exceeds 138% of the Federal Poverty Level, and then reduce the tax credit subsidy to $0 when you enroll in a health plan. When they ask for “Proof of Income” you can simply write a statement, title it AFFIDAVIT, and say that your income is derived from self-employment and cannot be known at this time, but that it will exceed 138% of FPL. Sign it, date it, have someone witness it, and upload it to CoveredCA.

Max, I totally agree with your comment but the reality at CC is different. First my application was defaulted into the Medical approval because a one time big payment was removed by the software. As a consultant is typical to have a one time payment. Then when talking with CC operator I was only recommended to take Medical although I ask to pay the full amount by myself and take the credit in 2015. So they are stuck with this idea that if your income is low NOW you MUST take Medical although I can earn later a million dollars! Or maybe an income that is in the range of subsidy. I was able to convince them that I will have an income and need to prove this by March 15. So it is not clear for CC that we have this option to pay upfront full premium regardless of the present income.

Dan …

I’m not certain I understand your comment. Persons with variable income who believe they will be eligible for premium tax credits MUST enroll in a QHP through the exchange. It’s a requirement of the PPACA. No one is trying to throw anyone off the exchange that I am aware of.

As for taking any tax credits now, there is no requirement to do this. A person may choose to pay the full premium and file for the credits in 2015 when the 2014 income tax return is filed.

To do that on CoveredCA, in the enrollment process, a person has the ability to adjust the amount of APTC they want to use from $0 to the maximum CoveredCA has calculated.

Why everybody wants to through someone with variable income off the CC exchange when we do not know what is the income at the end of the year. Why do not keep people in the exchange and reconcile at the end especially if I am willing to pay the full amount ? Why the CC website have the option “without subsidy” if is not helping at all? I thought the meaning is to have all the options open for the time we know the REAL income which is only on December 31 2014.

Tom … if you currently have no income and no genuine prospect for stable income on the horizon, you should apply showing $0 income and accept Medi-Cal eligibility which will not cost you anything in the form of premiums.

If your employment-income situation changes mid-year, then you will have experienced a triggering event (i.e., becoming eligible for APTCs) and can then enroll in a silver plan (possibly with cost sharing — you’d want to average your future income over the course of the entire year, which is what it will look like on paper when you file your tax return.

Thanks Max, That is how I read your comments. As a 60yo, unemployed or occasionally employed individual my income is highly variable. Based on 2013 income I am eligible for a significant subsidy but if I am able to find any reasonable and stable employment my premiums could increase 11X, for the cheapest silver plan. Any cost increase of 11X is, in fact if not bureaucratic definition, a life changing event. If I wish to be optimistic it appears I should sign up for catastrophic insurance only. I agree with the 30days, except that my income is so variable. I don’t know if projects will last a couple of days, weeks or months. It is all at the whim of the employer. That is a known reality for my demographic which the government chooses to ignore, again.

Tom …

The list of Special Enrollment Period “triggers” HAS been provided above by Phil, and below by me (the two lists are essentially the same, Phil’s is a bit paraphrased, mine is verbatim).

An increase in income is NOT a trigger for the SEP, but it is a reportable change of circumstance. More income means a reduction in tax credits. To avoid exposure to the “clawback” provision in the ACA (limited to $1500 in 2014), a person should report a significant increase in income to CoveredCA.

I don’t recall seeing a specific amount of time within which such changes should be reported, but IMMEDIATELY is always better than LATER, and beyond 30 days is simply waiting too long.

Dan …

When you submit your application to CoveredCA, you agree to report changes in income among other things. Mostly this means increases, which would reduce a person’s tax credits. You should report a reduction in income, too. If that makes you eligible for Medi-Cal, the PPACA says you are supposed to be on Medi-Cal.

If you don’t want to be exposed to this, you can forgo the tax credits and pay the full cost of private health insurance off the exchange.

A registered advisor for CoveredCA and another person who I spoke to at Anthem about an exchange plan both said a significant increase in income was a triggering event but it doesn’t fit with these comments. My concern was if I earn enough to loose subsidies & enhancements. Even becoming eligible for employer sponsored insurance isn’t eligible from the above list. Who Am I To Believe? Washington & CoveredCA both are clueless. The call lines never work. No where in the app process or any document I have read is it 30 days but both reps said it was 30. We still don’t have an official list of “Triggering.”

What if my income drops and I am not eligible for subsidy and private insurance. I mean the income is in the Medical category. Can Covered cancel my insurance and push me into Medical? Do I have the option to pay on my own all the premium? Is this a qualifying event?

To provide some additional context, here’s a link I found that confirms what Max Herr says…

https://www.healthcare.gov/what-if-i-currently-have-cobra-coverage/#question=my-cobra-coverage-ends-after-open-enrollment-closes-can-i-get-a-marketplace-plan-once-my-cobra-expires-even-outside-open-enrollment

Ken …

Expiration of one’s COBRA continuation is equivalent to loss of Minimum Essential Coverage, so it triggers a Special Enrollment Period. However, the rules change on January 1 and you will no longer be required to exhaust COBRA continuation before purchasing an individual health plan.

You can terminate COBRA at any time in the year, but the proper procedure is to apply for replacement coverage first.

What about if COBRA benefits expire mid-year? Is that similar to “Employer-sponsored plan will no longer be affordable or provide minimum value.”?

Roger’s comment about 30 days to report is incorrect. A Qualifying Event (in the list of 9 below — essentially the same as Phil’s above) extends for 60 days BEYOND the month of the event itself. A person may make an application for new health insurance or Medi-Cal at any time during the Special Enrollment Period, which can, effectively, be up to 90-91 days (New employment on March 2, terminating Medi-Cal eligibiity, but no Employer-sponsored QHP, equals 90 days == SEP requires enrollment in MEC on or before May 30).

The following is taken verbatim from a document addressing this issue posted by Washington State:

Under the Affordable Care Act, the following 9 events trigger a special enrollment period, that extends for two months (60 days) beyond the month of a triggering event:  A qualified individual and any dependents losing other minimum essential coverage (includes those circumstances described in 26 CFR 54.9801-6(a)(3)(i) through (iii) which include: loss of Medicaid and CHIP—as a result of a reported change in household income, or as a result of other circumstances)  A qualified individual gaining or becoming a dependent through marriage, birth, adoption, or placement for adoption  An individual, not previously lawfully present, gaining status as a citizen, national, or lawfully present individual in the U.S  Consistent with the Medicare Prescription Drug Program, a qualified individual experiencing an error in enrollment  An individual enrolled in a QHP adequately demonstrating to the Exchange that the QHP in which he or she is enrolled substantially violated a material provision of its contract  An individual becoming newly eligible or newly ineligible for advance payments of the premium tax credit or experiencing a change in eligibility for cost-sharing reductions (does not apply if they become eligible for an increase or decrease in their existing advance payments of the premium tax credit; however if an individual experiences a change in his or her existing payments of the premium tax credit in tandem with a change in level of cost-sharing reductions, the individual could qualify for this special enrollment period)  New QHPs offered through the Exchange becoming available to a qualified individual or enrollee as a result of a permanent move (includes Qualified individuals newly released from incarceration)  The individual is an Indian, as defined by the Indian Health Care Improvement Act.  A qualified individual or enrollee meeting other exceptional circumstances, as determined by the Exchange or HHS. Here is the link to the regulation for those who are interested, the special enrollment section is § 155.420. (general open enrollment is §155.410)

If you doubt this, you can follow this link to the actual words:

https://www.federalregister.gov/articles/2012/03/27/2012-6125/patient-protection-and-affordable-care-act-establishment-of-exchanges-and-qualified-health-plans

The language in fact is “life triggering event” although that sounds wrong. To complicate things more the sentence in the Exchange Agreement says, “Click here for a list of life triggering events” but there is no link you can click and therefore you need to ask forums like this what they might mean.

Loss of employment resulting in loss of MEC or major change in income making one eligible for Medi-Cal should be added to the list.

This is the wrong information. A customer only has 30 days to report a life triggering event.

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