Covered California, thị trường bảo hiểm sức khỏe tại California dưới Đạo luật Chăm sóc Sức khỏe Hợp lý (ACA), cho phép cá nhân và gia đình đăng ký hoặc thay đổi kế hoạch bảo hiểm sức khỏe của họ trong các giai đoạn cụ thể gọi là “Giai đoạn Đăng ký Mở cửa” và “Giai đoạn Đặc biệt.”
Dưới đây là một số Sự Kiện Trong Cuộc Sống (Qualifying Life Events – QLEs) phổ biến có thể khiến bạn được đủ điều kiện tham gia vào Giai đoạn Đặc biệt (Special Enrollment Period – SEP) tại Covered California:
- Mất Bảo Hiểm Khác: Nếu bạn mất bảo hiểm sức khỏe hiện tại (ví dụ: bảo hiểm do nhà tuyển dụng cung cấp, Medicaid hoặc một kế hoạch bảo hiểm cá nhân khác), bạn có thể đủ điều kiện tham gia vào Giai đoạn Đặc biệt. Điều này bao gồm các tình huống như mất việc làm, qua độ tuổi để không còn nằm trong kế hoạch của cha mẹ, hoặc việc kết thúc kế hoạch COBRA.
- Kết Hôn: Nếu bạn kết hôn, bạn có thể đăng ký vào một kế hoạch Covered California hoặc cập nhật kế hoạch hiện tại của bạn để bao gồm chồng hoặc vợ và con cái đủ điều kiện.
- Sinh Hoặc Nhận Nuôi Con: Việc sinh hoặc nhận nuôi con cho phép bạn đăng ký con cái của mình vào kế hoạch bảo hiểm sức khỏe của Covered California.
- Thay Đổi Kích Thước Gia Đình: Những thay đổi quan trọng trong gia đình của bạn, chẳng hạn như có người ở cùng hoặc trở thành người có trách nhiệm tài chính cho người phụ thuộc, có thể khiến bạn đủ điều kiện tham gia vào Giai đoạn Đặc biệt.
- Chuyển Nhà: Nếu bạn chuyển đến một khu vực mới có các kế hoạch sức khỏe khác hoặc nếu bạn chuyển ra khỏi khu vực phục vụ của kế hoạch sức khỏe của bạn, bạn có thể đủ điều kiện tham gia vào Giai đoạn Đặc biệt.
- Thay Đổi Thu Nhập: Nếu bạn trải qua thay đổi thu nhập có tác động đến đủ điều kiện của bạn để nhận trợ cấp cho phí bảo hiểm hoặc Medi-Cal, bạn có thể điều chỉnh kế hoạch Covered California của mình.
- Có Quyền Sở Hữu Công Dân Hoặc Tình Trạng Hợp Pháp Hoặc Thuộc Dân Tộc Ban Hành: Nếu bạn trở thành công dân Hoa Kỳ, có tình trạng hợp pháp hoặc trở thành thành viên của một bộ tộc được công nhận bởi liên bang, bạn có thể đủ điều kiện tham gia vào Giai đoạn Đặc biệt.
- Ra Khỏi Tù: Nếu bạn được ra khỏi tù, bạn có thể đủ điều kiện tham gia vào Giai đoạn Đặc biệt để đăng ký vào một kế hoạch Covered California.
- Tình Trạng Là Nạn Nhân Của Bạo Lực Gia Đình Hoặc Bỏ Rơi Bởi Vợ/Chồng: Nếu bạn là nạn nhân của bạo lực gia đình hoặc bị bỏ rơi bởi vợ/chồng và muốn đăng ký vào một kế hoạch khác với kế hoạch của người bạo lực, bạn có thể đủ điều kiện tham gia vào Giai đoạn Đặc biệt.
- Trở Thành Đủ Điều Kiện Để Nhận Bảo Hiểm Cho Người Da Đỏ/Người Eskimo Alaska: Thành viên của các bộ tộc được công nhận liên bang có thể đăng ký vào hoặc thay đổi kế hoạch mỗi tháng một lần.
Lưu ý rằng bạn thường có 60 ngày kể từ ngày Sự Kiện Trong Cuộc Sống xảy ra để đăng ký vào một kế hoạch Covered California hoặc thay đổi kế hoạch hiện tại của bạn. Nếu bạn bỏ lỡ cửa sổ này, bạn có thể phải đợi đến Giai đoạn Đăng ký Mở cửa hàng năm tiếp theo để đăng ký hoặc thay đổi trừ khi bạn đủ điều kiện cho một Giai đoạn Đặc biệt khác.
Khi bạn trải qua một Sự Kiện Trong Cuộc Sống, nên liên hệ với Covered California hoặc một người tư vấn đăng ký được chứng nhận để xác định xem bạn có đủ điều kiện tham gia vào Giai đoạn Đặc biệt và để hỗ trợ bạn trong quá trình đăng ký.
Qualifying Life Events Covered Californa
Covered California, the health insurance marketplace in California under the Affordable Care Act (ACA), allows individuals and families to enroll in or make changes to their health insurance plans during specific periods called “Open Enrollment” and “Special Enrollment” periods.
Here are some common Qualifying Life Events (QLEs) that may make you eligible for a Special Enrollment Period (SEP) in Covered California:
- Loss of Other Coverage: If you lose your existing health coverage (e.g., employer-sponsored coverage, Medicaid, or another individual health plan), you may qualify for a Special Enrollment Period. This includes situations where you lose coverage due to job loss, aging out of a parent’s plan, or the expiration of COBRA coverage.
- Marriage: If you get married, you can enroll in a Covered California plan or update your current plan to include your spouse and any eligible dependents.
- Birth or Adoption of a Child: The birth or adoption of a child allows you to enroll your child in a health plan through Covered California.
- Change in Household Size: Significant changes in your household, such as getting a new roommate or becoming financially responsible for a dependent, may qualify you for a Special Enrollment Period.
- Relocation: If you move to a new area where different health plans are available or if you move out of your health plan’s service area, you may be eligible for a Special Enrollment Period.
- Change in Income: If you experience a change in income that affects your eligibility for premium subsidies or Medi-Cal, you can adjust your Covered California plan accordingly.
- Gaining Citizenship, Lawful Presence, or Tribal Status: If you become a U.S. citizen, gain lawful presence, or become a member of a federally recognized tribe, you may be eligible for a Special Enrollment Period.
- Release from Incarceration: If you are released from incarceration, you may qualify for a Special Enrollment Period to enroll in a Covered California plan.
- Status as a Victim of Domestic Violence or Spousal Abandonment: If you are a victim of domestic violence or spousal abandonment and wish to enroll in a separate plan from your abuser, you may qualify for a Special Enrollment Period.
- Becoming Eligible for American Indian/Alaska Native Coverage: Members of federally recognized tribes can enroll in or change plans once per month.
It’s important to note that you typically have 60 days from the date of the Qualifying Life Event to enroll in a Covered California plan or make changes to your existing plan. If you miss this window, you may have to wait until the next Open Enrollment Period to enroll or make changes unless you qualify for another Special Enrollment Period.
When you experience a Qualifying Life Event, it’s advisable to contact Covered California or a certified enrollment counselor to determine your eligibility for a Special Enrollment Period and to assist you with the enrollment process.
Qualifying Life Events Covered Californa
https://www.coveredca.com/support/before-you-buy/qualifying-life-events/
If you experience a qualifying life event, you can enroll in a Covered California health insurance plan outside of the normal open-enrollment period. Most special-enrollment periods last 60 days from the date of the qualifying life event.
For most qualifying life events, your coverage will start on the first day of the following month after you select a plan.
Less than 150 percent of the federal poverty level
- For 2023, your expected income is less than $20,385 as a single person, less than $27,465 for a household of two people, less than $34,545 for a household of three people, or less than $41,625 for a household of four people. (For other household sizes, see the Federal Poverty Level Chart under the 150 percent column.)
Pandemic (e.g., COVID-19) or national public health emergency
- A pandemic or national public health emergency resulting in a declaration of a state of emergency at the state or national level.
Paid the penalty for not having health insurance
- Paid the Individual Shared Responsibility Penalty to California’s Franchise Tax Board because you didn’t have health insurance in the previous tax year.
Lost or will soon lose my health insurance
- You lose Medi-Cal coverage.
- You lose your employer-sponsored coverage.
- Your COBRA coverage ends, or you stop receiving government subsidies or employer contributions for your COBRA coverage. 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.
Affected by wildfires or other publicly declared state of emergency
- Experienced a natural or human-caused disaster (for example wildfires) that resulted in the declaration of a state of emergency in California.
Newly qualifies for health insurance stipend
- New driver for a ride sharing or delivery company as an independent contractor.
- Existing driver of a ride sharing or delivery company who expects to drive enough hours to receive the health care stipend.
Got married or entered into domestic partnership
- One or both members of the new couple can use the special enrollment period to enroll in coverage.
Had a baby, adopted a child, or began fostering a child
- The entire family can use the special enrollment period to enroll in coverage.
- If you receive a child in foster care, you will need to indicate “adopted a child” in the drop-down menu when you apply.
Permanently moved to or within California
- 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.
Gained citizenship/lawful presence
Returned from active-duty military service
- You have lost coverage after leaving active duty, reserve duty, or the California National Guard.
Domestic abuse or spousal abandonment
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.
Released from jail or prison
Other qualifying life event
- 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.
- You recently gained access to an individual coverage HRA (ICHRA) or you were newly provided a qualified small employer health reimbursement arrangement (QSEHRA).
- 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.
- You did not receive timely notice (and were otherwise reasonably unaware) of an event that may have qualified you for a special-enrollment period.
- 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 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 are enrolled in “share of cost” Medi-Cal, and have met your share of cost in one of the past two months. You may choose to keep your enrollment in share-of-cost Medi-Cal when you enroll in a Covered California plan. You can use this qualifying life event for a special-enrollment period only once in a calendar year.
- 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.
None of the above (Continue to review my application for Medi-Cal/Medi-Cal Access Program)
If none of these qualifying life events apply, you should still apply using “None of the above,” because you may be eligible for Medi-Cal or the Medi-Cal Access Program (MCAP) for pregnant women based on your income. Regardless of which life event you select, your application will still be reviewed for coverage through Medi-Cal and MCAP.
