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10 Ways to Qualify for a Special Enrollment Period

With the onset of the Affordable Care Act (aka Obamacare), enrolling in a health plan has been restricted to a particular time frame called Open Enrollment.  This generally happens toward the end of the calendar year, with new plans beginning January 1st of the following year.  But what do you do if something changes in your life and you need new health insurance mid-year?  You may or may not be able to get it.  Here are the 10 categories that will afford you a Special Enrollment Period (SEP) in which to enroll in a new health plan:

  1. Losing other qualifying coverage:
    • You were on Medi-Cal and no longer qualify
    • If you newly qualify for Medi-Cal, you can enroll at any time.
    • You had employer-sponsored coverage and lost/quit your job
    • You had COBRA and exhausted those benefits.  Dropping COBRA because it is too expensive DOES NOT qualify.  However, you do not have to accept COBRA if it is offered to you.
    • You no longer qualify for a student health plan through a university
    • You turn 26 years old and need to come off your parent’s plan
    • You turn 19 and no longer qualify for a ‘child only’ plan
    • You no longer qualify for military coverage
  2. Changes in household size
    • Marriage, divorce, legal separation
    • Birth or adoption of a child
    • Death
    • Any other situation where you lose a dependent or your status as a dependent
  3. Changes in residence
    • Permanently moved from out of state
    • Permanently moved within the state to a location that offers at least one new Covered CA plan to which you previously did not have access
    • Permanently moved within the state and your current plan is not offered in your new location
  4. Changes in eligibility for financial help
    • Gain or lose status with Medi-Cal
    • Lose your ‘share of cost’ with Medi-Cal by reaching your share of cost
  5. Defined types of errors made by the Marketplace, Plans, or Agents
    • You were given misinformation during the enrollment process
    • There were technical errors with the software during your enrollment
    • There were errors in the processing of your eligibility determination
  6. Release from jail or prison
  7. Gained Citizenship or Lawful Presence
  8. Member of a Federally recognized American Indian or Alaska Native tribe
    • Members have an open Special Enrollment Period and can enroll at any time
    • Members can change plans once every month
  9. Your provider (doctor) left the plan’s network AND you have one of the following:
    • Pregnancy
    • Terminal Illness
    • Acute Condition
    • Serious Chronic Condition
    • Care of a child between the ages of 0 – 36 months
    • Surgery or Procedure scheduled within 180 days of the provider’s change
  10. All Other Reasons
    • Natural disaster (fire, flood, hurricane, etc.)
    • You had a medical emergency that precluded you from enrolling during open enrollment
    • You are a victim of domestic violence or spousal abandonment
    • You have a court order to provide insurance for a dependent, even if you will not be claiming that dependent on your tax return.

It’s a long list to remember.  So, if you just remember that the circumstances must be beyond your control, you will probably find that you qualify for a Special Enrollment Period.  But be mindful:  your SEP is only 60 days long and starts the day your change happens.  If you miss your 60-day window, you will have to wait for the next Open Enrollment Period to receive a plan beginning the next year.

Unfortunately, California no longer allows interim, or short-term, plans to carry you through.  Your only options are the Marketplace (Covered CA) or purchasing something directly with the insurance company.  A health insurance broker (like Pronoeo Insurance Agency) can guide you.

Fixing Healthcare is Like Eating an Elephant

The cost of medical insurance in California (and nationwide) has spiraled out of control.  It is not uncommon for a married couple to be paying more for medical insurance than for their mortgage.  And then they can’t afford to use the insurance because of ridiculous deductibles and copays.

Factors:Average Annual Premiums 1999-2015

Unfortunately, it’s a lot like homelessness: there is no ONE underlying cause.  There are many factors that drive up the cost of healthcare:



  1. Fee-for-Service systems: providers (doctors and facilities) are paid per procedure so it incentivizes them to utilize many procedures and tests, even if it isn’t warranted by the diagnosis. On the flip-side, underpayment or low reimbursement of these procedures also encourages over-treatment because the providers don’t make enough to cover their costs.
  2. We have an aging population. Over 70% of the medical services you receive in your lifetime will be received in your retirement years.  As we age, we become less resilient to disease and physical injury.
  3. We want the latest drugs, technologies, services, and procedures to keep us healthy. But new on the market usually equates to higher priced treatment.
  4. Mergers and Acquisitions of health organizations have created near monopolies in the various areas of medical care. When there is no one to compete against, you can set your prices wherever you want.  M&A’s have caused the price of medical services to rise at a rate much higher than inflation.
  5. We live in a litigious society. People know that doctors and hospitals have to carry malpractice insurance and see them as a ‘deep pocket.’  Doctors are afraid of being sued (sometimes ‘again’), and so there is a propensity to utilize defensive treatment: prescribing something “just in case” there may be a medical issue, so they won’t get sued.
  6. With the rate of reimbursement falling for Primary Care Physicians (your general/family doctor), there are more specialists in this country than there are Primary Care Physicians. Specialists are paid much more than a family doctor.  Hence, we have a serious shortage of family physicians.
  7. The cost of medications keeps going up – even the ones that have been on the market for years. This one, the politicians probably COULD fix.  America is one of two countries worldwide that allow drug companies to advertise.  We are paying for their advertising expense through our high drug prices.  That’s why other countries don’t have a problem with high drug prices.

And I’m sure the list goes on and on.  So let’s just PICK ONE, and fix it.  Then we can work on the next one.  Focusing on one problem at a time allows more resources to go to its solution instead of just doing a little here and a little there and so nothing gets completed.  It’s just like eating an elephant – you can only do it one bite at a time.  When the elephant has been consumed, everyone will have access to AFFORDABLE HEALTHCARE.

Affordable Healthcare: An Oxymoron

Health Insurance with PenHealthcare has become such a political issue that the concept of “affordable healthcare” has vanished.

There is no single fix for obtaining affordable healthcare because the things making it unaffordable are as diverse as the people needing it.  Let’s look at just three:

Current Issues:

1. Cost of care for CHRONIC DISEASES and overall POOR HEALTH.

The reality is that people with chronic diseases and/or overall poor health have greater medical needs and expenses than the average person.  Medications, hospitals, ER and ambulance services are utilized more frequently by these individuals out of necessity, not because of system abuse.  Finding a system that makes their care affordable is tricky – someone has to pay for all that.

2. Availability and access to DOCTORS and MEDICAL FACILITIES.

The current system may give more insurance coverage to individuals, but that does not equate to access to doctors and medical facilities.  Reimbursements are so low, many doctors will not accept patients who are not part of an employer’s group policy.  Many doctors have refused to accept Medicaid and Medicare patients because of the low reimbursements.  The reality: it’s difficult to find a doctor, and when you do, you cannot get an appointment for weeks (or months).

3. QUALITY of available care.

Many of the providers that will accept the low reimbursements are rated poorly on sites on the internet.  They may be fine providers under normal circumstances.  But with low reimbursements, they are forced to push patients through as quickly as possible just so they can meet their overhead (rent, payroll, utilities, insurance, etc.).  Misdiagnoses is the THIRD leading cause of death in the US (John Hopkins 2016).  Doctors are forced to choose volume over quality.


There is a misconception among our politicians that affordable health insurance equals affordable healthcare.  There are two things wrong with that equation:

  1. If you are not subsidized by a government program for your health insurance, it is ANYTHING but affordable. Especially if you are between 60-65 years old.  Your monthly insurance premium could be more than your mortgage.
  2. Deductibles, copays and coinsurance are so high on these insurance plans that people are avoiding going to the doctor when sick or injured.

Having access to insurance does NOT mean you have access to healthcare.  Attempting to manage healthcare through the insurance industry is like relying on your auto mechanic for investment advice.  And if you want to muck it up further, get a politician involved.  YOU DON’T WANT SINGLE-PAYER.

Let’s work on actually addressing the causes of HEALTHCARE unaffordability and not INSURANCE affordability (a symptom).  Coverage without access is an empty promise.

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