​There are many factors that go into making a decision regarding health care coverage. With the Open Enrollment beginning soon, it is important to know what changes there are, given both issues stemming from the COVID-19 pandemic and changes in the Health Insurance Marketplace during 2020.

Open Enrollment

The Health Insurance Marketplace Open Enrollment Period runs from Sunday, Nov. 1 through Tuesday, Dec. 15, 2020.¹ Coverage begins Jan. 1, 2021.² If you do not enroll in a plan by Dec. 15, 2020, enrollment is not available at any other time of the year unless you qualify for a Special Enrollment Period.³

Automatic Enrollment

If you already have a Marketplace plan, you will be automatically enrolled into your current plan if it is still available in the Marketplace.⁴

If your current plan is no longer offered, HealthCare.gov will enroll you in a new plan that is as similar as possible to your 2020 plan. This means there is a chance you may be automatically enrolled into a plan that has a different type of network, a different metal level (bronze, silver, gold, platinum), or even a plan with a different insurer if your current insurer is no longer offering any plans in the Marketplace.

For these reasons, everyone with a Marketplace plan should review their coverage, research whether there are better options for 2021, and make sure they know what actions – if any – they need to take.

Special Enrollment Periods

Typically, you have 60 days after a life-changing (“triggering”) event for a Special Enrollment Period (SEP) into a Marketplace Plan outside of Open Enrollment.⁵ Triggering events include, but are not limited to, losing other qualifying coverage, getting married, having a child, moving, or other “exceptional circumstances.”⁶

Federal Emergency Management Agency’s Special Enrollment Period

In August 2018, the Centers for Medicare & Medicaid Services (CMS) clarified that an “exceptional circumstance” includes when an individual is affected by a Federal Emergency Management Agency (FEMA) declared emergency or major disaster.⁷

This means that in 2020 you have additional opportunities to enroll if you meet the following criteria:

• You reside in an area during the incident period of a FEMA-declared disaster or emergency (currently, all states are covered under FEMA’s COVID-19 pandemic national emergency declaration);⁸

• You were eligible for another SEP; and

• You failed to enroll with the SEP for which you were eligible due to impacts from the FEMA-declared disaster (in this case, impacts from COVID-19).

The Healthcare.gov application now asks whether you have had any SEP-qualifying events since Jan. 1, 2020, rather than the typical 60 days.

This means that if you were eligible for an SEP at any time since Jan. 1, 2020, but did not enroll, you may still qualify for coverage. However, if you have not had any SEP-qualifying events since Jan. 1, you are not eligible for the FEMA SEP. The COVID-19 pandemic alone does not create an SEP.

Retirement, Medicare, & Marketplace

With COVID-19 forcing many businesses to shut down, reduce hours, or furlough/lay off employees, many individuals are deciding to retire earlier than they may have planned. Therefore, it is important to understand how Medicare and the Marketplace work together.

The main consideration is the order of enrollment. There are two possibilities:

• If you are already enrolled in a Marketplace plan, you can add Medicare, but you will lose any premium tax credit subsidies.⁹

• If you are already enrolled in Medicare, you cannot enroll in a Marketplace plan, because a Marketplace plan is considered duplicate coverage. For this reason, penalties can be imposed against any insurance agent who knowingly sells or issues a Marketplace plan to a Medicare beneficiary.¹⁰

Finally, it is important to distinguish the Marketplace Open Enrollment Period with Medicare’s Part D Annual Enrollment Period for prescription drug coverage, which runs from Oct. 15 through Dec. 7, 2020.¹¹ Coverage for these plans also begin Jan. 1, 2021.¹²

For more information, see Healthcare.gov.

This article was originally published on the State Bar of Wisconsin’s Public Interest Law Section Blog. The blog is a section benefit. Visit the State Bar sections or the Public Interest Law Section web pages to learn more about the benefits of section membership.

Endnotes

¹ 45 C.F.R. § 155.410(e)(3).

² Id. at (f)(2)(i).

³ Id. at (a)(2).

⁴ 45 C.F.R. § 155.420(g).

⁵ Id. at (c)(1).

⁶ Id. at (d).

⁷ CMS, Center for Consumer Information & Insurance Oversight, mem. (Aug. 9, 2018).

⁸ See FEMA.gov.

⁹ 26 C.F.R. § 1.36B-2.

¹⁰ 42 C.F.R. § 1003.1100(d)(1).

¹¹ 42 C.F.R. § 423.38(b)(3).

¹² 42 C.F.R. § 423.40(b)(1).