The AFFORDABLE CARE ACT: New Pathway to Coverage
By: Beth Sufian
On January 28, 2021, President Biden directed the Department of Health and Human Services (HHS) to expand access to Affordable Care Act (ACA) coverage. The order did not change the existing ACA statute but requested operational changes within the administration’s existing authority. The ACA permits HHS to provide special enrollment periods for common special circumstances (like loss of coverage, change in income, marriage, the birth of a child, etc.) and in “exceptional circumstances.” The Secretary of HHS determined that the ongoing COVID-19 pandemic was an exceptional circumstance that warranted a special enrollment period to allow individuals to enroll in individual health coverage in the insurance marketplace operated by HSS on www.HealthCare.gov. The new COVID-19 emergency special enrollment period began on February 15 and will continue to May 15, 2021. During this special enrollment period, individuals may enroll in health coverage which will become effective on the first day of the month after a consumer enrolls through www.healthcare.gov. The new COVID-19 emergency special enrollment period is an additional opportunity for individuals to enroll in an ACA plan. For those who have lost their job during the past year this special enrollment period provides a chance to purchase a health insurance policy to cover medical costs.
Many people are eligible for premium help from the government depending on household income. Some in the CF community have been misinformed about the cost of ACA plan policies. The federal government reports that a majority of people who have ACA plans pay between $85-$100 a month in premiums because they receive premium help from the federal government to help pay their premiums. The policy premiums cannot be increased if a person has cystic fibrosis or some other health condition. ACA plans have to provide coverage for 45 different healthcare services including medication.
The new special enrollment period does not affect the enrollment of individuals who may have enrolled in an ACA plan during the usual annual open enrollment period for 2021 which ran from November 1, 2020, to December 15, 2020. The new COVID-19 emergency special enrollment period is available to consumers in the 36 states served by Marketplaces that use the HealthCare.gov platform. All qualifying individuals eligible to enroll in coverage through the www.HealthCare.gov platform may submit a new application for coverage during the special enrollment period. Also, individuals currently enrolled in an ACA plan through the HealthCare.gov platform will be permitted to update an existing application or coverage. Individuals eligible to enroll under the new special enrollment period will be able to select a plan with coverage that starts prospectively the first day of the month after plan selection. Enrollees have up to thirty days after they submit their application to choose a plan. Enrolling for ACA coverage under the emergency special enrollment period will not require any documentation of a special qualifying event, such as loss of a job or a COVID19 diagnosis. Enrollees claiming eligibility under the COVID-19 emergency special enrollment period will only need to provide the information usually required to determine eligibility and enroll in coverage.
If a person missed the open enrollment period or applied for an ACA plan under circumstances that did not qualify for special enrollment, the person may now be able to enroll under the new COVID-19 emergency special enrollment period.
HHS strongly encourages states operating their own Marketplace platforms to make a similar enrollment opportunity available to consumers in their states. State-based marketplaces are not required to allow for a special enrollment period similar to the new federal rules, but many states are allowing citizens to enroll in plans offered by their state marketplace. The COVID-19 emergency special enrollment period is a new and additional pathway to ACA enrollment. The other ways of enrolling in an ACA plan are still available if you qualify. You are still able to enroll during an open enrollment period; The next open enrollment will sometime during the end of 2021 for coverage beginning in 2022. Outside of the annual open enrollment period, individuals can enroll during a special enrollment period due based on a qualifying event, like losing other coverage, change in income, getting married, or having or adopting a child.
Finally, the COVID-19 emergency special enrollment period is not a part of the proposed COVID19 legislation. It is already effective and qualifying individuals are able to enroll now under the new COVID-19 emergency special enrollment period, but only until May 15, 2021.
Nothing in this article is meant to be legal advice about a specific situation and is only meant to be information.
About the Author: Beth Sufian has practiced law for 30 years. Beth is 54 and has cystic fibrosis. Beth is the current Treasurer of CF Roundtable. You may contact her with your legal questions about CF-related issues at: CFLegal@sufianpassamano.com.