Health insurance in many situations is not a “one size fits all” solution. Our market is a diverse one, with many of our clients being of varying age, health, and socio-economic status. While it can sometimes be easier to focus on the most “average” of enrollees, special circumstances are not all that rare and should not be overlooked.
Many industries are having to adapt to new ways of doing things in light of COVID-19 and the insurance industry is no different. The ability to take things as they come and equipping yourself to handle any circumstance are the keys to being able to successfully help your clients.
Advice for clients who missed their OEP
When clients have missed the Open Enrollment Period (OEP), there are still options for them to get coverage. They may qualify for a Special Enrollment Period (SEP), but there are more restrictions.
Qualifying life events
Certain life events can help enrollees who missed OEP get coverage when they need it. Qualifying event can vary a little from state to state, but here is a good example of the most common qualifiers:
- Losing your job-based health coverage
- Moving to a new ZIP code or county
- A student moving from the place they attend school
- Getting married
- Divorced or legally separated and lost health insurance
- Having a baby or adopting a child
- Turning 26
- On an ACA Marketplace plan with someone who dies and as a result, you’re no longer eligible for your current health plan
- If you are no longer eligible for Medicaid or the Children’s Health Insurance Program (CHIP)
- Becoming a U.S. citizen
- Leaving incarceration
- Starting or ending service as an AmeriCorps State and National, VISTA, or NCCC member
In order to use a life event as the basis for special enrollment, your client must enroll within a certain timeframe. Generally, this is 60 days before or after the event. If your client misses this window, however, they will need to wait until they experience another qualifying life event or Open Enrollment starts again.
It’s important for you to keep your clients informed of this kind of situation so that you are able to help them in the appropriate time frame. The sooner they can complete applications as a qualifying life event occurs, the sooner they will be covered.
The timeliness of Special Enrollment Periods makes it crucial to regularly follow up with your clients throughout the year. Staying connected enables you to be there for them when they need you.
How to appeal a Marketplace decision
In the event that you have a client who disagrees with a decision made by the Health Insurance Marketplace — such as one that states they are not eligible for a SEP — you can help them appeal the decision.
After they receive an Eligibility Notice, an enrollee has 90 days to submit an appeal. If you try to appeal after the 90-day window, explain why and your client may be eligible for a “good cause” extension.
Your client can download or print the Marketplace Eligibility Appeal Request Form and submit it via the website, fax, or mail. All tax filers must sign the form and any documents supporting the appeal should be attached.
Don’t forget: when filing an appeal, your client should remain enrolled in their current plan and continue to pay premiums. If for whatever reason, your client cannot wait for the standard return time on an appeal, they may request an expedited appeal.
New changes in 2022
It shouldn’t come as a surprise that there are a few changes this year to the ACA Marketplace. You probably noticed many of them during Open Enrollment. There are a few, however, to take note of as they may affect your clients who are eligible for a SEP.
People with very low income have added time to enroll
Starting this year, individuals with very low income will be allowed to enroll throughout the year. Each month, a new special enrollment opportunity will be offered, including plans with no premiums and reduced deductible. To qualify, these individuals must have income up to 150% of the federal poverty level.
While OEP is still the best time to get health insurance coverage, this opportunity could affect millions of people and allow them the chance to sign up for a low-cost healthcare option.
New surprise medical bills protection will take effect
The fear of a surprise medical bill is one that has haunted all of us at one time or another. This year, that fear can subside. Beginning January 1, all insurance plans, including marketplace plans, must cover emergency services at the in-network rate.
This means that emergency room facilities and doctors cannot bill out-of-network patients for more than their in-network patients. These protections will also apply to non-emergency care at in-network facilities.
Get ahead with current clients as best as you can
While Covid-19 remains prevalent, it’s all the more important to help clients get ahead if and when life events force them to begin or change coverage via SEP. It’s more of a service to them than a sales strategy for agents to remind past clients not to miss their SEP window. If they do, they’ll have to wait to apply for coverage until the next Open Enrollment Period.
Staying on top of health insurance industry changes and your clients’ life events is the best way to ensure that each individual is taken care of.
Keeping track of everything can be difficult when you have so much else going on. That’s where AgentLink can help.
No matter what the needs of your business are, AgentLink offers services that can benefit you, your clients, and your business. By partnering with AgentLink, you have the support and resources you need to adapt and succeed while taking care of your individual clients.
Contact our Benefits Department to learn more about what we can do for you.
