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How does the special enrollment period work?

 

Special enrollment in California

  • You qualify for a special enrollment period if you have a certain life event.
  • You generally have 60 days from the date of your qualifying life event to enroll for health coverage or change your plan.
  • In most cases, you need to have proof of your life event.
  • In some cases, you have 60 days before and 60 days after your qualifying life event to apply for coverage or change your plan. Examples include:
    • Loss of Coverage
    • Child support order or other court order to cover a dependent
    • Change in eligibility for employer health coverage
    • Contract violation
    • Determination by Covered CA

2 Choose the qualifying life event that best matches your situation:

If you lose your employer-provided coverage because:


  • You lose your job.
  • Your work hours are reduced, so you no longer qualify for coverage.
  • The person who covers you on an employer health plan dies.
  • You're a dependent on a health plan and your marital status changes due to a legal separation or divorce, so your eligibility as a dependent ends.
  • You no longer live or work in the service area, and no other group health coverage is available to you.
  • You're part of a group of employees that are no longer offered coverage from your employer.
  • A dependent child becomes too old to qualify as a dependent.
  • Your employer stops contributing premium payments for your group health coverage.
  • Your COBRA (Consolidated Omnibus Budget Reconciliation Act) coverage ends.
  • Your retiree coverage is discontinued when your employer declares federal Chapter 11 bankruptcy.
  • The person who covers you on his or her employer health plan becomes entitled to Medicare.
  • Your group plan is renewing or ending on a date other than January 1.
  • You're a victim of domestic abuse or spousal abandonment and you or your dependents on the same application want to apply for coverage separately from your abuser or the spouse who abandoned you.

If you lose Medi-Cal because:


  • You have a change in income.
  • 60 days pass after delivering a child or your pregnancy fails.
  • You lose what's known as "Medically Needy" coverage, which is special Medicaid coverage for people with too much income or too many assets to qualify for Medicaid, but who have high medical expenses. This type of special enrollment period may occur only once per calendar year.

If you lose your Community Health Care Program (Northern California), Child Health Program (Southern California) coverage


If you lose your Part A, Parts A and B, or Part C Medicare coverage


If you lose individual plan coverage because:


  • Your individual plan is renewing or ending on a date other than January 1.
  • You become ineligible for individual coverage. (For example, this can happen when someone reaches the age limit for being covered as a dependent child.)
  • You lose certain types of veteran's coverage.
  • You lose TRICARE coverage.
  • You lose certain self-funded student health coverage.
  • You're a victim of domestic abuse or spousal abandonment and you or your dependents on the same application want to apply for coverage separately from your abuser or the spouse who abandoned you.
  • Your military coverage ends because you return from active duty.
  • The health plan you're enrolled in has broken a material part of your contract with them.

It's NOT a qualifying event if you lose coverage because:

  • You didn't pay your premiums.
  • Your plan was retroactively cancelled because of fraud or misrepresenting the facts on purpose.
  • You have Medicare Part B coverage and didn't have any other coverage.
  • You voluntarily ended your coverage.
  • You had temporary or short-term coverage like traveler’s insurance.
  • If you have a baby, adopt a child, or get married — or foster a child if your plan includes coverage for foster children. In the case of marriage, you or your spouse must have had for at least one full day in the past 60 days to qualify.
  • If you lose a dependent because the dependent reaches an age where he or she no longer qualifies to be covered under your health plan, or the subscriber or dependent dies.
  • If you lose a dependent because of a divorce, dissolution of domestic partnership, or legal separation.

Note: If the subscriber or dependent dies, you qualify for a special enrollment period only if you're enrolled under the same plan as the person who died.

If you've had a child in the past couple of months.


If your qualifying event is the birth of a child, you can have your plan start on the date your child was born or on the first day of the month following that date, as long as you apply within 60 days of your child's birth.

This means you can cover your newborn's care for up to 60 days before you apply for coverage. But keep in mind that if you choose a start date in the past, you'll need to pay the premiums for that time -- plus the standard first month's premium.

For example, if you have a baby on March 1 and submit your application on April 15, you can ask for March 1 to be your start date, but you'll need to include the premium payments for March, April, and May with your application.

If you got married or registered a domestic partnership


You have to submit proof of prior coverage for one spouse for at least one full day unless you were living in an area where no qualified health plan was offered through your marketplace. Your state’s marketplace can tell you if no qualified health plan was available. You may send a screenshot from the marketplace website or other documentation the marketplace provides.

If a state or federal court orders that you or your dependent be covered as a dependent.

  • Permanent relocation means moving from another service area to a Kaiser Permanente service area and having a different choice of health plans.
  • You must have minimum essential coverage for all applicants for at least one full day in the past 60 days, unless you moved from a foreign country or a United States territory, or you moved from a county that did not offer a qualified health plan, to qualify based on permanent relocation.
  • You'll also need to provide proof of your old and new residential address.

If you were recently released from jail, prison, or another form of incarceration, you may enroll through your state health insurance marketplace or directly through Kaiser Permanente.

If your state marketplace decides that you qualify for a special enrollment period because of unusual circumstances, such as an error or lack of action on the part of your state marketplace, or for any other reason.

If you're newly entitled to have health care coverage because of an immigration status change. In this case, you may only enroll in a plan offered through your state health insurance marketplace.

For more information, visit your state marketplace or healthcare.gov, or call 1-800-318-2596. You can also call Kaiser Permanente for help at 1-800-494-5314.

  • Your state health insurance marketplace will decide if you qualify for a monthly special enrollment period to enroll in or change health care coverage. If you do qualify, you may only enroll in a plan through your state marketplace.
  • For more information, visit Covered California or call 1-800-318-2596. You can also call Kaiser Permanente for help at 1-800-494-5314.

If your state marketplace determines that you qualify for a special enrollment period because you were wrongly informed that you had coverage already, and didn't apply for coverage during open enrollment for that reason.

If you were under active care for certain conditions with a provider that no longer participates in your health plan. Examples of conditions include an acute condition, a serious chronic condition, pregnancy, terminal illness, care of a newborn, or authorized nonelective surgeries.

  • If your household income level changes and, as a result, you or your dependents become eligible — or ineligible — for financial help. (Dependents must be enrolled in the same plan as the subscriber.)
  • If you live in a state that didn't expand Medicaid and aren't enrolled in a Medicaid plan, and you become eligible for an advanced premium tax credit because your household income increases above 100% of the federal poverty level.
  • If a new determination of Medicaid or CHIP ineligibility makes you eligible for marketplace enrollment.

Note: For more information about eligibility for federal financial assistance, visit your state marketplace or healthcare.gov or call 1-800-318-2596. You can also call Kaiser Permanente for help at 1-800-494-5314.

  • If your coverage through your employer doesn't qualify as , so you're now eligible for a premium tax credit - for example, if your employer discontinues or changes that coverage.

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