ACA Small Group Special Enrollment Period 101

It’s not easy for business owners to offer health insurance. It’s expensive to offer coverage because the premiums are high, and if you don’t have enough employees (70% of your staff) to meet the participation requirements you aren’t even able to opt into a group health plan. But did you know there’s a window under the Affordable Care Act (ACA) known as the Special Enrollment Period?

Let’s dive into what that means for businesses in the small group market.

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What is the Small Group Special Enrollment Period?

The Small Group Special Enrollment Period under the Affordable Care Act (ACA) is an essential opportunity for small business owners. This period, spanning from November 15 to December 15 annually, is when insurance carriers offer a unique enrollment window for small businesses. This time is important for businesses considering offering health insurance benefits to their employees.

One of the primary advantages of this period is the financial relief it provides to employers. During this time, businesses are not required to contribute to their employees’ health insurance premiums, which can be a significant cost-saving measure. Additionally, the enrollment requirements are minimal – only one employee needs to enroll in the health plan for it to be established.

Business owners should mark December 15 on their calendars as the final day for completing all employee enrollments. This deadline is critical because coverage will only commence on January 1 if all procedures are completed by this date. To ensure a smooth and timely enrollment process, it’s recommended to start discussions with an insurance broker well in advance.

Additional Special Enrollment Periods for Individuals

Apart from the Small Group Special Enrollment Period, there are other periods designed for individuals who experience certain life events. These Special Enrollment Periods (SEPs) are available for individuals who encounter scenarios like losing existing health coverage, changing living situations, getting married, having a baby, or adopting a child. Typically, individuals have a 60-day window, either before or after these events, to enroll in a health plan.

Qualifying Life Events and Their Impact

Qualifying Life Events (QLEs) are specific occurrences in one’s life that open the door to a Special Enrollment Period. These include:

• Loss of health coverage: This might involve losing job-based, individual, or student health plans or losing eligibility for government programs like Medicare, Medicaid, or CHIP.
• Changes in household: Events such as getting married, getting divorced, having a baby, adopting a child, or experiencing a family death.
• Changes in residence: Moving to a new ZIP code or county, changes in living situations for students or seasonal workers, and moving to or from shelters or transitional housing.
• Other significant events: Changes in income affecting coverage eligibility, gaining tribal membership, becoming a U.S. citizen, release from incarceration, or beginning or ending service in AmeriCorps.

In addition to these, special circumstances like severe medical conditions, natural disasters, or successful appeals with the Marketplace can also make someone eligible for a SEP.

How to Apply for a Special Enrollment Period

The process of applying for a SEP is straightforward but requires attention to detail. Here are the steps:

1. Verify Eligibility: First, determine if you qualify for a SEP based on a QLE, and do so within 60 days of the event.
2. Visit the Health Insurance Marketplace: Go to HealthCare.gov or your state’s health insurance exchange website. Here, you’ll either log in to an existing account or create a new one.
3. Complete an Application: Fill out an application to find out if you’re eligible for a private plan or programs like Medicaid or CHIP.
4. Document Submission: If you qualify for a SEP, you’ll need to provide documents as indicated on your Marketplace Eligibility Notice to confirm your eligibility.
5. Enrollment and Coverage Start: After your SEP is confirmed and you have paid your first premium, your coverage will commence, depending on when you choose a plan and the nature of your QLE.

Coverage Start Dates and Their Importance

Understanding when your coverage starts is vital. Generally, the coverage begins on the first of the month after you complete your enrollment. However, in certain scenarios, like the birth or adoption of a child, coverage can be retroactively applied to the date of the birth or adoption.

Each state has the authority to set its own rules regarding the start dates of coverage. In some instances, states may require that all special enrollment periods follow a uniform rule of coverage starting on the first of the month after enrollment, regardless of when the application was submitted.

For situations like loss of coverage, it’s possible to apply for a new plan 60 days before losing your current coverage. This proactive approach can help avoid any gaps in your health insurance coverage.

Finalizing Your Coverage

The last step in this process is the payment of your first premium. It’s important to remember that your coverage will only start once this payment is made. This final step is essential in ensuring that you and your employees, if applicable, have the necessary health coverage in place when needed.

Navigating Post-Application Processes for Special Enrollment Periods

Responding to the Eligibility Notice

After applying for a Special Enrollment Period (SEP), one of the first steps to take is to check the eligibility notice. This notice is a vital document that outlines whether additional information or documents are needed to confirm your eligibility. If you’re asked to provide more documents, it’s essential to do so within 30 days of selecting a plan. A prompt response to this notice is key to advancing your application process and ensuring that your health coverage is not delayed.

Utilizing the Marketplace Call Center

For any uncertainties or questions regarding your SEP application, the Marketplace Call Center is a valuable resource. The representatives at the call center can offer detailed information about the status of your application and assist you with the enrollment process. This direct line of communication can be instrumental in clarifying any confusion and helping you navigate the next steps.

The Appeal Process

If you find yourself disagreeing with a decision made by the Marketplace, you have the option to file an appeal. This appeal must be lodged within 90 days of receiving your eligibility notice. However, if you’ve surpassed this 90-day window, it’s still possible to appeal, but you’ll need to provide a reasonable explanation for the delay. This appeal process is an important right, allowing you to contest decisions that you believe are incorrect or unfair.

Reapplication and Exploring Other Options

In cases where your SEP application is denied, reapplying is a viable option. Alternatively, exploring other available options is advisable. For instance, if you are denied Medicaid due to income constraints or other eligibility criteria, you may still be eligible for health coverage through the Marketplace during a 60-day SEP. This flexibility ensures that you have multiple avenues to secure health coverage, even if your initial application does not succeed.

Determining SEP Eligibility

Understanding your eligibility for a Special Enrollment Period is critical. Eligibility is often based on life events such as losing health coverage, relocating, marriage, birth of a child, or adoption. If there’s any uncertainty about qualifying for an SEP, reaching out to the Marketplace Call Center or consulting with a licensed insurance professional is advisable. These experts can provide tailored guidance and help you evaluate your options based on your specific circumstances.

Bottom Line

The best route to take before applying for Special Enrollment is to weigh your options. Speak with a professional and take the time to decide if you want to contribute anything to the premiums. Prepare ahead of time.

If you do it right, you’ll start the next year offering a critical benefit to your employees. This added perk could potentially increase your retention rate.

Remember, this is not official legal advice. If you have questions about the ACA, it’s best to consult an employment lawyer.