Working with the Marketplace can be daunting and confusing. Having a Marketplace agent or broker to help you navigate the system is very important. This is for two reasons – firstly, an agent knows what special events qualify for an open enrollment period and can guide you accordingly (particularly if there are multiple special events), and secondly, an agent knows how to fill out the questions being asked on the Marketplace to ensure that your case and the unique situation is represented correctly and understood by the Marketplace.
When it comes to filling out your application on Marketplace, you have to pay attention to all the little quirks and the little fine print in parentheses, because that could help determine whether you’re eligible or not for a special enrollment period. You may erroneously enter something and make yourself either eligible (and then you find out later you really weren’t and you’re stuck with the penalty and paying back the subsidy), or you make yourself ineligible (and you didn’t enroll when you could have had coverage). Using an experienced agent is truly beneficial to you. It does not cost you anything because we are paid by the insurance carriers, and your premium is not based on whether you use an agent or not. Most importantly, an agent should know if your special events do qualify you for open enrollment or not.
Have you heard of special qualifying events that can trigger an open enrollment period? Recently, I have had a number of people referred to me because they currently have special events going on in their lives and can possibly qualify to begin or change their healthcare plan. It is important to note that there is a common misconception out there about these special events; most people have the idea that if they have a qualifying event, they can automatically sign up for health insurance. This is not entirely true. This is because the Marketplace rules are ever-changing. Last year, the rules were very different because we had open enrollment all the way through August, and there was only a very short window where you weren’t able to enroll. If you were on unemployment last year, or just needed to sign up, you could. This year, the rules have changed. The confusion comes in when people think, “Well, I’ve gotten married or divorced or have had a baby, I can sign up”. A lot of times, you can only make changes if you’re losing coverage due to those life events.
The Marketplace has rules and systems in place to determine eligibility for an open enrollment period. There are a couple of interesting situations where it is hard to figure out if the special event qualifies or not, such as immigration status. Remember, immigration status doesn’t automatically trigger a special event. An example would be, a person who is over 65, and the family is bringing this elderly parent to come to live here in this country so that they can care for them. But the parent is not eligible for Medicare, because they have not lived in the country for five years. But the Marketplace system wants to know if they’re losing coverage (they are not) and then, why they don’t have Medicare. So it’s not always very simple, and knowing how to answer the questions on Marketplace will make all the difference.
In order to provide some more concrete information for my clients, I have tried to log into the Marketplace and find examples of who can get coverage, when, and what triggered the special event. From my research, there’s no way for me to know every situation without having experienced it firsthand. And even then it can be different for each case. I’m finding what was one way for one person, may not be the same way for another person. And so really, truly each situation is unique. There are some general guidelines, if you have a life change event, we certainly want to explore to see if you’re eligible for a special enrollment period.
There are so many factors that play into your eligibility, that’s why it’s important to have an agent or broker help you understand the Marketplace and to know where to look for the answers. It’s daunting to try to do this on your own because you may not get the right response. Sometimes I don’t even get the response I should be getting, and I have to go back and review the application and see what they’re asking because sometimes they ask the questions in a way that we think you’re answering, but that’s not the answer they want.
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