Helping Employees and Patients Navigate New Waters: The Interaction of Marketplace Coverage, COBRA and Medicare

The following is an update to the article entitled, “Helping Employees and Patients Navigate New Waters: The Interaction of Marketplace Coverage, COBRA and Medicare,” by Howard Bye-Torre and Kiran Griffith published in the February 2015 edition of the Health Lawyer.

As outlined in our article, persons may only enroll in Qualified Health Plans (“QHP”) at the Marketplaces during the Marketplace’s open and special enrollment periods. In late February, 2015, HHS issued final regulations altering a few of the Marketplace’s open and special enrollment period rules, which are effective April 28, 2015.ⁱ

Marketplace's Open Enrollment Period for 2016
The Marketplace’s open enrollment period for 2016 will be from November 1, 2015 through January 31, 2016.ⁱⁱ Coverage will be effective on January 1, 2016 for persons who enroll on or before December 15, 2015. Coverage for persons enrolling in Marketplace coverage from December 16, 2015 through January 15, 2016 will be effective February 1, 2016, and coverage for persons enrolling after January 15, 2016 will be March 1, 2016.ⁱⁱⁱ

New Special Enrollment Period Rules for 2016
The final regulations tinker with some of the triggering events for the special enrollment rights and the effective dates of the QHP coverage elected during a special enrollment period. Highlights of the changes include the following:

• The final regulations add a new optional special enrollment triggering event that, if adopted by a Marketplace, grants a special enrollment period for enrollees (persons already enrolled in a QHP) that allows the election of a different QHP if (1) the enrollee loses a dependent; (2) an enrollee is no longer considered a dependent due to divorce or legal separation; or (3) an enrollee or his or her dependent dies.^iv For special enrollments due to a death, the coverage must be effective as of the first day of the month following the election, unless the Marketplace allows the enrollee or dependent to elect a later coverage date allowed by the regulations (such as the 1st day of the second month after the date of the election, if the election is made after the 15th of the month).^v For example, if a dependent of an enrollee dies on May 16th, and the enrollee elects a new QHP on May 26th, coverage under the new QHP must be effective on June 1, unless the Marketplace allows the enrollee to select July 1 as the effective date.
• By January 1, 2017, Marketplaces must allow a person who gains access to a new QHP due to a change in residence to enroll in the new QHP 60 days before the move (in addition to the current rule, which allows such enrollment 60 days after the move).^vi If a person enrolls in a QHP due to a change in residence prior to or on the date of the move, enrollment in the new QHP must be effective no later than the first day of the month following the loss of the prior coverage.^vii
• For a special enrollment due to a court order, the Marketplace QHP coverage must now be effective retroactively back to date of the court order. The Marketplace may also permit the person to elect a later coverage date allowed by the regulations (such as the 1st day of the month after the date of enrollment).^viii

^{i 80 Fed. Reg. 10749, 10866–10867 (Feb. 27, 2015).
ii 45 C.F.R. § 155.410(e)(2). The proposed regulations suggested that HHS might adopt an open enrollment period for 2016 from October 1 to December 15 of 2015. 79 Fed. Reg. 70673, 70752 (Nov. 26, 2014). The open enrollment period for 2015 was November 15, 2014 to February 15, 2015. 45 C.F.R. § 155.410(e)(1).
iii 45 C.F.R. § 155.410(f)(2).
iv 45 C.F.R. § 155.420(d)(2)(ii).
v 45 C.F.R. § 155.420(b)(2)(vi).
vi 45 C.F.R. § 155.420(c)(2).
vii 45 C.F.R. § 155.420(b)(2)(iv).
viii 45 C.F.R. § 155.420(b)(2)(v), (d)(2)(i).}

"Helping Employees and Patients Navigate New Waters: The Interaction of Marketplace Coverage, COBRA and Medicare" was originally published in The Health Lawyer, February, 2015