What
to do if you missed the deadline to get health insurance?
The open enrollment to get health insurance for year
2019 in California has ended (the time frame to apply for health insurance was
October 15, 2018- January 15, 2019). The open enrollment varied in different
states, but now it is closed everywhere.
So what you do if you’ve missed the open enrollment?
Well, you still might have some options. Let’s take
a look.
Option 1. If you missed the open enrollment but experience
a certain life event during the year, you have up to 60 days to apply for major
medical insurance. Let’s explore what kind of life events might qualify you for
this special enrollment.
1. You Lost or will soon lose your health
insurance
Examples:
You lose Medi-Cal coverage.
You lose your employer-sponsored coverage.
Your COBRA coverage is exhausted. Note: Not paying
your COBRA premium is not considered loss of coverage.
You are no longer eligible for student health
coverage.
You turn 26 years old and are no longer eligible for
a parent’s plan.
You turn 19 years old and are no longer eligible for
a child-only plan.
2. Permanently moved to/within California
Examples:
You move to California from out of state.
You move within California and gain access to at
least one new Covered California health insurance plan.
3. Had a baby or adopted a child
(If you receive a child in foster care, you will
also qualify for a special enrollment period)
Examples:
A child is born, adopted or received into foster
care. The entire family can use the special enrollment period to enroll in
coverage.
If you place your child for adoption or foster care,
you can use a special enrollment period to enroll in coverage.
4. Got married or entered into domestic partnership
Example:
One or both members of the new couple can use the
special enrollment period to enroll in coverage.
5. Returned from active duty military service - You
have lost coverage after leaving active duty, reserve duty, or the California
National Guard.
6. Released from jail or prison
7. Gained citizenship/lawful presence- If You become a
citizen, national, or permanent legal resident – you have an option to get
health insurance during the special enrollment.
8. Federally Recognized American Indian/Alaska Native
If you are a member of a federally recognized
American Indian tribe, you can enroll at any time and change plans once per
month.
9. Other qualifying life events
· You are already enrolled in a Covered California
plan and become newly eligible or ineligible for tax credits or cost-sharing
reductions.
· You are already enrolled in a Covered California
plan and you lose a dependent or lose your status as a dependent due to
divorce, legal separation, dissolution of domestic partnership, or death.
· Misconduct or misinformation occurred during your
enrollment, including:
An agent, certified
enroller, Service Center representative or other authorized representative
enrolled you in a plan that you did not want to enroll in, failed to enroll you
in any plan or failed to calculate premium assistance for which you were
eligible.
· Misrepresentation or erroneous enrollment,
including:
Incorrect eligibility
determination. This includes if you applied during open enrollment and were
initially told you were eligible for Medi-Cal and then later
determined not to be eligible for Medi-Cal.
· The health plan did not receive your information due
to technical issues.
· An error in processing your verification documents
resulted in an incorrect eligibility result.
· Incorrect plan data were displayed when you selected
a plan: Data errors on premiums, benefits or copay/deductibles were displayed;
incorrect plans were displayed; or a family could not enroll together in a
single plan.
· Your health plan violated its contract.
· Exceptional circumstances occurred on or around plan
selection deadlines, including natural disasters and medical emergencies.
· You received a certificate of exemption for hardship
from Health and Human Services for a month or months during the coverage year
but lost eligibility for the hardship exemption outside of an open enrollment
period.
· You and your dependents, if any, are victims of
domestic abuse or spousal abandonment.
· You are required by court order to provide health
insurance for a child who was been determined ineligible for Medi-Cal and CHIP,
even if you are not the party who expects to claim the child as a tax
dependent.
· You lose “share of cost” Medi-Cal coverage by
reaching your share of cost.
· You are a member of AmeriCorps/VISTA/National
Civilian Community Corps:
If you entered AmeriCorps or
one of the other organizations listed above outside of open enrollment.
· If you ended your service with one of the
organizations listed above.
· You have a non-calendar year health plan (including
“grandfathered” and “non-grandfathered” health insurance plan) outside of
Covered California that has expired or will soon expire, and you would like to
switch to a Covered California health insurance plan instead of renewing your
current plan.
· Your provider left the health plan network while you
were receiving care for one of the following conditions:
Pregnancy
Terminal illness
An acute condition
A serious chronic condition
The care of a newborn child
between birth and age 36 months
A surgery or other procedure
that will occur within 180 days of the termination or start date.
Option No. 2
If none of the above
qualifying life events apply to you, then you can look into the alternative
health plans. Now, it is very important to keep in mind that short-term
insurance have been banned in certain places. As of January 1, 2019 – short term
insurance plans are illegal in California.
Also, beware of other types
of coverage that is not considered insurance by law. I am not saying that those
polices are bad, just don’t assume that accident & sickness hospital
indemnity plans are the same as major insurance. They are not and you should
carefully read the fine print before you agree to get any of those plans.
For example, let’s explore
the Faith Based Health Insurance Plans. These are non
insurance by law, but are an alternative option that many would consider.
Here are some of the plans:
Catastrophic Plans
Dental and Vision Plans
Let’s look at what these
plans cover:
What iscovered by these plans
1. Telemedicine. Telemedicine is
included in most programs offered by Unity HealthShareSM and Aliera Healthcare
as your first line of defense. Your membership provides you and your family
24/7/365 access to a U.S. Board certified medical doctor.
2. Preventive. Most programs from
either Unity HealthshareSM or Aliera provide everyone with the necessities of
the 63 preventive care services as outlined by the United States Preventive
Task force. (Excludes CarePlus Advantage.) Preventive care includes the PCP
office visit and does not require a co-expense or consult fee.
3. Labs &
Diagnostics. Your labs and diagnostics are covered when visiting a PCP
or urgent care facility in network when your plan includes primary and urgent
care. For labs at hospitals or other facilities, your MSRA will apply and you
will be required to pay a co-expense of $25.
4. Urgent Care. If your plan
provides cost sharing for urgent care, you will have the added benefit of
enjoying the ability to choose an urgent care facility in lieu of an emergency
room. See the Appendix for any urgent
care options and any limitations to plan.
5. Primary Care. Depending on your
plan choice, primary care is at the core of preventing medical issues from
escalating into a more catastrophic need. See Appendix for the specific plan details.
6. Specialty Care. Specialty care is
included in most plans, but has limits defined by your specific plan design. Refer to the Appendix for specific details of MSRA and
co-expense requirements.
7. X-rays. X-rays listed on
your plan details in the Appendix are for imaging services at PCP or urgent
care facilities only and requires a $25 read fee per view at time of service.
Your MSRA will apply to all other X-rays. MRI, CT Scans and other diagnostics
must be paid with your MSRA before cost sharing is provided.
8. Chronic Maintenance. Chronic
maintenance is eligible when a member has chosen a plan with chronic
maintenance specifically included and a listing of the maximum number of
allowable visits.
9. Emergency Room. Emergency room
services for stabilization or initiation of treatment of a medical emergency
condition provided on an outpatient basis at a hospital, clinic, or urgent care
facility, including when hospital admission occurs within twenty-three (23)
hours of emergency room treatment.
10. Hospitalization. Hospital charges
for inpatient or outpatient hospital treatment or surgery for a medically
diagnosed condition.
11. Surgical Benefits.Non life-threatening
surgical benefits are not available for the first 60 days of membership for
Premium plans and all other plans require 6 month wait period. Please verify
eligibility by calling Members Services before receiving any surgical services.
12. Prescription Drugs. The AlieraCare
plan includes a service by RX Valet, which includes cost sharing for
prescription drugs. See Appendix for details.
13. Physical Therapy. Up to six (6)
visits per membership year for physical therapy by a licensed physical
therapist.
14. Ambulance. Emergency land or
air ambulance transportation to the nearest medical facility capable of
providing the medically necessary care to avoid seriously jeopardizing the
sharing member’s life or health.
15. Naturopathic and/or
Alternative Treatments. Does not included chiropractic services
16. Prosthetics and
their replacement, if medically necessary. This is not an
eligible sharing expense
17. Medical Costs
incurred outside the United States. Charges for the
care and treatment of a medically diagnosed condition when treatment outside
the United States is financially beneficial or when traveling or residing
outside the United States. Eligibility of such charges are subject to all other
provisions of the Guidelines. Medical billing is requested to be submitted in
English and converted to U.S. currency.
18. Smoking Cessation. Members with
preventive coverage who have acknowledged they smoke and made an additional
contribution are provided the opportunity to obtain free smoking cessation
medication and counseling.
19. Competitive Sports. Plan holders who
participate in organized and/or sanctioned competitive sports are eligible for
$5,000 (max) of sharing per incident at an emergency room, subject to the
member-shared responsibility amount.
20. Maternity. Maternity medical
expenses are only eligible for sharing in certain Plans. Please see the Appendix for your specific plan design. Medical
expenses for maternity ending in a delivery by an emergency cesarean section
that is medically necessary are eligible for sharing up to $8,000 subject to
the applicable Member Shared Responsibility Amount. Medical expenses for a
newborn arising from complications at the time of delivery, including, but not
limited to, premature birth, are treated as a separate incident and limited to
$50,000 of eligible sharing, subject to the Member Shared Responsibility
Amount.
Now, let’s take a look at
what is not covered by these plans:
LIMITS OF SHARING (MAXIMUM PAYABLE)
Total eligible needs
shared from member contributions are limited as defined in this section and as
further limited in writing to the individual member.
1. Lifetime Limits.
$1,000,000: the maximum amount shared for eligible needs over the course of an
individual member’s lifetime.
2. Annual Limits. The
maximum amount shared for eligible needs per member per 12 month plan term.
3. Per Term. The limit
for each term of a sharing plan. Generally, means annually except in the case
of short-term cost sharing.
4. Per Incident. The
occurrence of one particular sickness, illness, or accident.
5. Cancer Limits when
applicable. Cancer is limited to a maximum per term of $500,000 when applicable
6. Member Shared
Responsibility Amounts (MSRA). Eligible needs are limited to the amounts in
excess of the MSRA, which are applied per individual member per the plan year.
7. MSRA(s). The eligible
amount that does not qualify for sharing based on the membership type chosen by
the member.
8. Office Visit/Urgent
Care. Office visits, in particular, primary and urgent, have certain limits and
inclusions. Please refer to the Appendix for your specific plan.
9. Non-Affiliated
Practitioner. Services rendered by a non-affiliated practitioner will not be
eligible for sharing nor will any amount be applied to your MRSA unless
specified differently in the plan details contained herein..
10. Organ Transplant
Limit. Eligible needs requiring organ transplant may be shared up to a maximum
of $150,000 per member. This includes all costs in conjunction with the actual
transplant procedure. Needs requiring multiple organ transplants will be
considered on a case-by-case basis.
11. Cost Sharing for
Pre-Existing Conditions. Cost sharing is not available for pre-exising
conditions for the first two years of membership.
12. Overnight Sleep
Testing Limit. All components of a polysomnogram must be completed in one
session. A second overnight test will not be eligible for sharing under any
circumstance. Overnight sleep testing must be medically necessary and will
require pre-authorization (see item 8). Allowed charges will not exceed the
Usual, Customary, and Reasonable charges for the area.
What isnot covered by these plans?
Medical Expenses not
generally shared by HCSM Only needs incurred on or after the membership
effective date are eligible for sharing under the membership instructions. The
member (or the member’s provider) must submit a request for sharing in the
manner and format specified by Unity HealthShareSM.
All participating
members have a responsibility to abide by the Members’ Rights and
Responsibilities published by Unity HealthShareSM and included at the end of
these guidelines. Needs arising from any one of the following are not eligible
for sharing under the membership clearing house instructions:
1. Any medical care
outside of a hospital, except in the case of a needed surgery due to an
accident. Members may be able to use out-patient facilities based upon the
nature of the medical need and at the sole discretion of Unity HealthShareSM.
In addition, some plans of Unity HealthShareSM include primary, urgent
, and specialty care. See the Appendix for your plan specifics.
2. Treatment or
referrals received or obtained from any family member including, but not
limited to, father, mother, aunt, uncle, grandparent, sibling, cousin,
dependent, or any in-laws.
3. Pre-existing
Conditions. Pre-existing conditions may vary based on plan option. Please see
Appendix for specific plan details.
4. Illness or injuries
caused by member negligence or for which the member has acted negligently in
obtaining treatment. This could be documented by, but is not limited to, review
of medical records or treatment plans by a licensed medical physician.
5. Procedures or
treatments that are not recognized and approved by the American Medical
Association (AMA) or that are illegal. Includes procedures not approved by the
AMA for a given application, procedures still in clinical trials, procedures
that are classified as experimental, or unproven interventions and therapies.
6. Lifestyles or
activities engaged in after the application date that conflicts with the
Statement of Beliefs (on the membership application).
7. Transportation (e.g.,
ambulance, etc.) for conditions that are not life-threatening, unless failure
to immediately transport the member will seriously jeopardize the member’s
life; the additional expense for transportation to a facility that is not the
nearest facility capable of providing medically necessary care; or charges in
excess of $10,000 for transportation by air. Member Guide 15
8. Congenital birth
defects.
9. Elective cosmetic
surgery.
10. Breast implants
(placement, replacement, or removal) and complications related to breast
implants, including abnormal mammograms, unless related to an otherwise
eligible need.
11. Elective abortion of
a viable fetus/embryo, unless medically necessary to protect the life of the
mother.
12. Infertility testing
or treatment, as well as any birth control measures to prevent conception
(i.e., the pill, IUDs, shots, etc.)
13. Sterilization or
reversals (vasectomy and tubal ligation).
14. Hysterectomy without
first obtaining two independent opinions (neither physician may be a partner or
other affiliate of the other). Both doctors must examine the patient prior to
surgery and both must find that a hysterectomy is medically necessary. The
member is responsible to ensure that both physicians submit medical necessity
to Unity HealthShareSM prior to surgery. Failure to follow these procedures
will result in a finding of ineligibility for sharing by the membership.
15. Weight control and
management including nutritional counseling for weight loss, weight gain, or
health maintenance. 16. Hospital stays exceeding 60 days per medical need or
additional charges for a private hospital room if a semiprivate hospital room
is available.
17. Any exams,
physicals, or tests for which there are no specific medical symptoms, diagnosis
in advance, or risk assessment testing.
18. Adult immunizations,
HPV immunizations, and flu shots unless covered under an Aliera Healthcare part
of the plan.
19. Chelation.
20. Physical therapy or
occupational therapy that is not pre-authorized. Pre-authorized treatments are
limited to a combined 6 visits in any calendar year.
21. Charges for
emergency room visits and/or surgical removal for foreign objects placed in
nose or ears by a child over five (5) years of age. Removal of foreign objects
that can be done in an office setting will be reviewed under regular MSRAs or
the Office Visit consult fee options.
22. Medication or
procedures not requiring a prescription.
23. Purchase or rental
of durable or reusable equipment or devices (e.g. oxygen, orthotics, hearing
aids, prosthetics, and external braces), including associated supplies,
diagnostic testing, or office visits.
24. Needs for active
members submitted 9 months after the date of treatment. Needs for inactive
members submitted 6 months after the date of treatment.
25. Dental services and
procedures, including periodontics, orthodontics, temporomandibular joint
disorder (TMJ), or orthognathic surgery. Includes hospital charges for dental
work done under general anesthesiology. Dental work required during surgery from
an accident shall be eligible for cost sharing when the dental work is required
after an accident and while the member is still admitted to a hospital.
26. Optometry, vision
services, glasses, contacts, supplies, vision therapy, refraction services, or office
visits.
27. Psychiatric or
psychological counseling, testing, treatment, medication, and hospitalization.
28. Mental or
psychiatric health, learning disability, developmental delay, autism, behavior
disorders, eating disorders, neuropsychological testing, alcohol/substance
abuse counseling, attention deficit disorder, or hyperactivity.
29. Speech therapy
(except for a deficit arising from stroke/trauma).
30. Circumcisions.
31. Self/inflicted or
intentional injuries.
32. Acts of war.
33. Exposure to nuclear
fuel, explosives, or waste.
34. Occupational injury
resulting from an injury incurred while performing any activity for profit.
35. Consumption of a
prescription drug not prescribed for the member or prescription drug prescribed
for the member and taken in excess that causes an adverse reaction; illicit
drug use by a member.
36. Illness or injury
caused by the illegal activities of the member or the member’s family,
including misdemeanors and felonies, regardless of whether or not charges are
filed.
37. Treatment, care, or
services that is not medically necessary.
38. Emergency room
services, unless treatment at an emergency room is the only legitimate option
because of the severity of the condition and lack of availability of treatment
at an alternative facility.
39. Sexually transmitted
diseases.
40. Diseases, including
HIV/AIDS, due to tattoos, body piercing, or life-style choices. 41. Allergy
testing or immunotherapy treatment.
42. Second surgeries are
eligible for sharing based on member’s treatment plan and are subject to third
party case management approval. Second surgeries on a previously eligible
surgical need are not eligible unless the Member Guide 16 member has followed
through with the treatment plan laid out for him or her by their physician or
complications occur within 15 days of eligible surgery.
43. Genetic testing and
counseling.
44. Handling charges,
conveyance fees, stat fees, shipping/handling fees, administration fees, missed
appointment fees, telephone/email consultations, or additional charges for
services supplied in an after-hours setting.
45. Drug testing unless
required by membership.
46. Sexual dysfunction
services.
47. Cancer sharing
eligibility is different based on plan option chosen. AlieraCare plans have a
12 month wait period for cancer. Sharing is available the 1st day of the 13
month of continuous membership. Any pre-existing or recurring cancer condition
is not eligible for sharing. Cancer sharing will not be available for individuals
who have cancer at the time of or five (5) years prior to application. If
cancer existed outside of the 5-year time frame of a pre-exisitng look-back,
the following must be met in the five (5) years prior to application, to be
eligible for future, non-recurring cancer incidents. 1. The condition had not
been treated nor was future treatment prescribed/planned; 2. The condition had
not produced harmful sypmtoms (only benign symptoms); 3. The condition had not
deteriorated.
48. Adenoid removal surgery
eligible for sharing only at 50% if member has had a prior surgery to remove
tonsils and the adenoids were not removed at the same time.
49. Personal aircraft
includes hang gliders, parasails, ultra-lights, hot air balloons, sky/diving,
and any other aircraft not operated by a commercially licensed public carrier.
50. Extreme sports:
Sports that voluntarily put an individual in a life-threatening situation.
Sports such as but not limited to “free climb” rock climbing, parachuting,
fighting, matrial arts, racing, cliff diving, powerboat racing, air racing,
motorcycle racing, extreme skiing, wingsuit, etc… First 60 Days of
Participation. For sixty (60) days after Enrollment Date as a Sharing Member,
medical expenses for any reason, other than accidents, illness or injury, are
not eligible for sharing among members.
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Your website is very beautiful or Articles. I love it thank you for sharing for everyone. Licensed Agents standing by for Medicare Enrollments
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