Ask the Expert: ComPro – What’s next with HealthCare Reform?

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Individuals and families

The Open Enrollment for individuals that opened October 1, 2013 is now closed.  Individual health insurance policies cannot be purchased for the remainder of 2014, either through the Marketplace or directly from an insurance company, unless you qualify for a Special Enrollment Period (SEP).  A SEP occurs when you have a qualifying life event or a complex situation related to the Marketplace.

Examples of a qualifying life event include:

• Marriage

• Having a baby, adopting a child, or placing a child for adoption or foster care

• Moving outside your insurer’s coverage area

• Gaining citizenship

• Losing other health insurance coverage due to

• Changing jobs • Divorce • Aging off a parent’s plan

• Exhausting COBRA benefits • Losing eligibility for Medicaid or CHIP

A Special Enrollment Period will normally last 60 days following life events that involve a change in family status.  Job-based plans generally allow a SEP of 30 days.  A SEP may also be granted when you have faced a serious medical condition or natural disaster that kept you from enrolling in a plan during the Open Enrollment; an enrollment error occurred on the Marketplace or in the state Medicaid system; or you were working on an enrollment issue that didn’t get resolved before March 31.

For more information on Special Enrollment Periods:

Many individual policies are in-force and will renew during 2014 on the policy anniversary date.  If the health insurance company offers to replace the old policy with an ACA compliant policy at renewal, the policyholder will NOT qualify for a Special Enrollment Period.  The only options available to the policyholder will be (1) accept the replacement policy for the remainder of 2014, (2) purchase a short-term plan for the remainder of 2014, or (3) go without coverage.  Options 2 and 3 will be subject to paying the penalty for not having ACA compliant coverage.  More importantly, options 2 and 3 will result in drastically reduced health insurance coverage.

The Open Enrollment for 2015 is November 15, 2014 through February 15, 2015.

Employer Sponsored Health Insurance Plans

The Open Enrollment dates do not apply to group insurance plans. The Affordable Care Act (ACA) divides employer plans into Small Group and Large Group.

Small Group Plans (less than 50 full-time equivalent employees) will be modified to comply with the ACA when the policy renews in 2014.  The benefits and method of calculating premiums will change.  Employers are evaluating how the group plan impacts employees and their family’s access to financial assistance on the Marketplace.  The “affordability test” feature of the ACA frequently results in disqualifying family members of an employee from Marketplace assistance.

Large Group Plans (50 or more full-time equivalent employees) have been given additional time to comply with the ACA.  The Employer Mandate (aka Employer Shared Responsibility) requires that large employers provide affordable health insurance that provides a minimum level of coverage to their full-time employees.  A large employer that fails to offer the coverage or has an employee receive financial assistance from the Marketplace will be subject to penalties.  This provision of the ACA was originally scheduled to be effective on 1/1/14, but was delayed to 1/1/15.  Employers with 50 to 99 employees were granted an additional year (until 1/1/16) to comply.

Final regulations on the Employer Shared Responsibility provisions were issued by the IRS and Treasury on Feb 10, 2014. See

by Chris McPike, Vice President


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