New Exchange Special Enrollment Periods for Certain Individuals

Each Exchange must have an initial open enrollment period, an annual open enrollment period, and certain special enrollment periods, under the Affordable Care Act (ACA). During one of the permitted enrollment periods individuals will only be able to enroll through an Exchange. The initial open enrollment period is Oct. 1, 2013, through March 31, 2014.

The Centers for Medicare & Medicaid Services (CMS) issued two separate pieces of guidance providing the following special enrollment periods (SEPs) in the federally-facilitated Exchange (FFE), on March 26, 2014:


SEP for “In Line” Individuals—those who have begun the enrollment process but haven’t finished—as of March 31; and


Limited Circumstance SEPs for individuals who were not able to enroll during the initial open enrollment period due to certain limited circumstances.

These SEPs allow individuals to enroll in Exchange coverage after the initial open enrollment period closes if certain conditions are met.

Overview of Special Enrollment in Exchanges

Following certain triggering events, such as marriage or birth of a child, individuals may be allowed an SEP in an Exchange. SEPs permit individuals to enroll in a qualified health plan (QHP) outside of open enrollment.

Similar to those applicable during initial enrollment, the effective date of any coverage elected during an SEP follows rules. This means that coverage would generally be effective as of the first day of the month for elections made by the 15th of the preceding month, and on the first day of the second following month for elections made between the 16th and the last day of a given month. Special rules apply when birth, adoption or placement of a child is the special enrollment triggering event, however.

The Exchange may set an appropriate effective date, for SEPs that are triggered by mistakes, contract violations, exceptional circumstances and misconduct.

nurse New Exchange Special Enrollment Periods for Certain Individuals SEPs for “In Line” Individuals


Despite efforts to meet the deadline, CMS has expressed concern over whether high consumer traffic leading up to the March 31 enrollment deadline could potentially keep consumers from completing the enrollment process.

CMS will provide an SEP for consumers in the PPF who are “in line” as of March 31, should this occur. This means that consumers who tried to enroll during the open enrollment period, but did not complete the process by March 31, will be allowed a limited amount of additional time to finish the application and enrollment process.

As long as consumers who were “in line” pay their first month’s premium on time, it is anticipated that enrollments made in the limited time after March 31 will have a May 1 coverage effective date. This is the coverage effective date that consumers would have had it they were able to complete enrollment by March 31, and is the normal effective date for enrollments between March 16 and April 15.

CMS will process paper applications received by April 7, for consumers who were “in line” with paper applications (or whose applications were pending submission or review of supporting documentation) on March 31. These consumers will be able to select a plan through April 30, and coverage will be effective May 1.

This guidance applies in FFEs and state partnership Exchanges. State-based Exchanges have the option to offer similar SEPs.


For more information please contact The Benefits Firm.

Ph: (502) 451-4560

620 S. 3rd Street, Suite 102 Louisville, KY 40202

President Obama extends ACA transition policy for current health plans

Millions of Americans received notices in late 2013 informing them that their health insurance plans were being canceled because they did not comply with the Affordable Care Act (ACA). Media and Congress criticized President Obama, saying that this contradicted his promise that consumers could keep their current plans under ACA if they chose.


So on Nov. 14, 2013, Obama announced a transition relief policy for 2014 for non-grandfathered coverage in small group and individual health insurance. If allowed by their states, this policy lets health insurers renew enrollees’ current policies without adopting all of the ACA’s reforms for 2014.


On March 5, 2014, the Department of Health and Human Services (HHS) extended the original transition relief policy for two years, to policy years beginning on or before Oct. 1, 2016. As a result, individuals and small businesses may be able to keep their non-ACA compliant coverage through 2017. Insurers that issue a policy under transitional relief in 2014 may renew them at any time through Oct. 1, 2016. In addition, affected individuals and small businesses may choose to re-enroll in the coverage through Oct. 1, 2016.


dr President Obama extends ACA transition policy for current health plans

Because the insurance market is regulated in large part at the state level, state governors or insurance commissioners have to allow transition relief in their own states. California, Connecticut, Washington, Minnesota, New York, Indiana, Vermont and Rhode Island did not allow insurers to use the original transition policy. Some states are allowing renewals with certain requirements.


Policies that are renewed under the extended transition relief will be considered in compliance with specified ACA reforms. Just like in the original transition relief policy, issuers that renew coverage under the extended transition relief must provide a notice to affected enrollees. Transition relief also applies to large employers that currently purchase large group insurance but will be redefined by the ACA as small employers purchasing insurance in the small group market as of Jan. 1, 2016.


According to HHS, the transition relief extension is intended to ensure that consumers have multiple health insurance coverage options, and that states will continue to have flexibility in their own markets. Some critics have said that the extension was issued to avoid a new round of policy cancellations shortly before the November 2014 elections.


HHS outlined the original transition relief policy in a letter to state insurance commissioners. Click here to read the letter. To learn more about how the policy may affect you, please contact The Benefits Firm.


Ph: (502) 451-4560

620 S. 3rd Street, Suite 102 Louisville, KY 40202

Final Regulations on the 90-day Waiting Period Limit

For plan years beginning on or after Jan. 1, 2014, the Affordable Care Act (ACA) prohibits group health plans and group health insurance issuers from applying a waiting period that exceeds 90 days.


The Departments of Labor (DOL), Health and Human Services (HHS), and the Treasury (the Departments) released final regulations on the 90-day waiting period. The regulations apply for plan years beginning on or after Jan. 1, 2015.


Overview of the 90-day waiting period
A waiting period is the period of time before coverage becomes effective for an eligible employee or dependent. All calendar days are counted, beginning on the enrollment date. The waiting-period does not require an employer to offer coverage to any employee, including part-time employees.


Permissible eligibility conditions – reasonable orientation periods
An employee or dependent is eligible to enroll in a plan when he/she has met the plan’s eligibility conditions. Examples of eligibility conditions:


• Being in an eligible job classification; or


• Achieving job-related licensure requirements specified in the plan’s terms.


Completing a reasonable and bona fide employment-based orientation period may be imposed as a condition for coverage. During an orientation period, the Departments envision that:


• An employer and employee could evaluate if the employment situation was satisfactory for each party; and


• Standard orientation processes would begin.


Proposed regulations include one month as the maximum length of any orientation period. This one-month maximum begins any day of a calendar month and is determined by adding one calendar month and then subtracting one calendar day.


If a plan conditions eligibility on completing a reasonable employment-based orientation period, the eligibility condition would comply with the 90-day waiting period if the orientation period did not exceed one month and the maximum 90-day waiting period would begin on the first day after the orientation period.


Rehired employees and employees changing job classifications
A former employee who is rehired may be treated as newly eligible for coverage. A plan or issuer may require the individual to meet the plan’s eligibility criteria and again satisfy the plan’s waiting period.


untitled2 Final Regulations on the 90 day Waiting Period LimitInsurance issuer compliance
The 90-day waiting period limit applies to the plan and the issuer offering coverage. However, the issuer will not violate the 90-day waiting period limit requirements if it:


• Requires the plan sponsor to make a representation regarding the terms of eligibility conditions or waiting period; and


• Has no knowledge of a waiting period that would exceed the 90-day period.


Effective date
The Departments proposed that the 90-day waiting period limit would apply for plan years beginning on or after Jan. 1, 2014, for both grandfathered and non-grandfathered group plans and insurance issuers offering group coverage.


The regulations apply to group plans and group insurance issuers for plan years beginning on or after Jan. 1, 2015.


Additional information
Please contact The Benefits Firm for additional information on the 90-day waiting period limit.



Source: Departments of Labor, Health and Human Services and the Treasury

Employer Mandate Transition Relief

Initially, the Affordable Care Act (ACA) was scheduled to impose a penalty on all large employers who did not offer minimum essential coverage to all full-time employees. In February 2014, transition rules were released that allows for the staggering of these penalties on certain large employers.


Applicable large employers must provide minimum essential coverage to at least 95% of their full-time employees (and dependants). However, the transition rules allow for this regulation to be staggered over two years. The first year (2015) at least 70% must be covered and the second year and following 95% must be covered.


This is intended to provide relief to employers who provide coverage to some employees (those who work 35 hours or more a week), but not all (those who work 30-34 hours a week).


gov Employer Mandate Transition Relief

What is the Penalty for Failing to Provide Coverage?


In general, the penalty for not offering coverage to substantially all full-time employees (and dependents) is equal to the number of all full-time employees (minus 30 full-time employees) multiplied by one-twelfth of $2,000 for each calendar month. The final regulations include transition relief for 2015 that allows employers with 100 or more full-time employees (including full-time equivalent employees) to reduce their full-time employee count by 80 when calculating the penalty.


New Large Employers


In the event that an employer is a new large employer, these employers have until April 1 of the first year of being a large employer to provide coverage to their full-time employees.


For more information please contact The Benefits Firm.

Ph: (502) 451-4560

620 S. 3rd Street, Suite 102 Louisville, KY 40202

ACA Exchange Lawsuit

untitled ACA Exchange LawsuitThe Affordable Care Act (ACA) created health insurance subsidies to help eligible individuals and families purchase health insurance through an Exchange, which are designed to make coverage through an Exchange more affordable.


There are two types of subsidies: cost-sharing reductions and premium tax credits. They vary based on out-of-pocket costs and household income.


In states that did not establish their own Exchanges, these Exchanges are called Federally Facilitated Exchanges (FFE). The ACA and the IRS allows for subsidies in all states, even those who do not have established Exchanges. As a result, employers and individuals filed a lawsuit (Halbig vs. Sebelius) challenging the ability of the federal government to provide tax credits where there were only FFE’s. A federal district court judge rejected this challenge, ruling that subsidies can be provided to individuals in states without Exchanges.


This may have significant implications for employers as a result of the ACA’s employer mandate. Under the employer mandate, large employers may face penalties if they do not offer coverage to their full-time employees that meet certain requirements.


However, penalties apply only if an employee receives a subsidy to buy coverage through an Exchange. If the subsidy is available only in state-based Exchanges, employers would not be subject to penalties.


While this current lawsuit did not go through, there are additional pending lawsuits in other states that may impact the availability of subsidies in states that have FFE.


For additional information please contact The Benefits Firm.

Ph: (502) 451-4560

620 S. 3rd Street, Suite 102 Louisville, KY 40202