We’re in the biggest open enrollment period of my lifetime. Open Enrollment is when people who don’t have a plan can get a plan and those who have a plan can change plans without penalty. Open Enrollment is a common feature in any non-NHS system including the German, Dutch and Swiss as well as the American commercial and Exchange operations.
Open Enrollment is an attempt to manage adverse selection. Open Enrollment creates uncertainty which insurance companies can statistically price instead of certainty. For instance, in a buy at any point environment, the rational thing for me to do would be to carry a very cheap catastrophic policy in order to cover me in case I get hit by a bus. However, if I go to the doctor on Tuesday morning for some strange bruising in my legs, and Wednesday afternoon, I get the “Congratulations, you have cancer” phone call, under a buy at any time scenario, my rational response would be to go buy the super platinum insurance policy. A limited open enrollment period will see people who get the “Congratulations you have cancer” phone call during the enrollment plan select the highest benefit but it guards against someone policy jumping six months later. It will also see someone who got the cancer call four months ago select the highest benefit level possible.
It is not a perfect filtering device, there is no such thing besides universal enrollment with either single payer or significant back-end risk transfer payments between multiple payers. But it is a decent device that forces people to treat health insurance as insurance against future risks instead of a cost-sharing pool for known events.
However, life changes, and this creates the concept of qualifying events. Qualifying events are situations that allow people to buy or switch policies outside of normal enrollment periods and to do so without penalties. The basic idea behind a qualifying event is dramatic life and family changes. When Kid #2 was born, he was a qualifying event as well as a pooping machine. When I lost my job several years ago, that was a qualifying event. When I got married to the best woman in the world (for me at least), that was a qualifying event. When my family moved three states, that was a qualifying event.
PPACA/Obamacare also uses the open enrollment system for risk management. The first year has an open enrollment period of six months (Oct. 1 to March 31, 2014). Going forward, the open enrollment period for the Exchanges will be 56 days in late Fall. However PPACA will also have the qualifying event criteria for people to buy on the Exchange outside of open enrollment. The qualifying events are the regular ones such as changes in jobs, changes in family size through marriage, divorce, births, adoptions and deaths, changes in location although a move across the street won’t qualify, but a move out of the designated selling/service area of the previously bought policy will qualify. Additionally, changes in previous insurance status will matter; if an employer drops coverage in July for his employees, that is a qualifying event or if a person makes too much now for Medicaid, that is a qualifying event, or if a person ages into Medicare, that is a qualifying event for people to get rid of their Exchange plan.
Nick
I’ve been wondering about qualifying events. Thank for writing.
Any thoughts on my situation? I’m currently living abroad. I have an address in Colorado, but for tax purposes I’m a non-resident and don’t pay CO taxes. (I do have to pay some Federal taxes.)
I do intend on calling the CO helpline at some point, but if you happen to know my options, I’d appreciate it.
1. Do I have to buy insurance?
2. If I get sick abroad and decide to move home, will I be able to use that as a qualifying event?
Aimai
I love you for explaining this.
Betty Cracker
You do a good job of explaining the insurance industry’s byzantine machinations. It’s a shame that such a task is necessary — the reach of a single payer system exceeding our political grasp at present. But since it is, I’m glad you’re around to do it.
Guy
@Nick: This IRS publication might be of help to you. Item #12 sounds relevant to your situation.
http://www.irs.gov/uac/Questions-and-Answers-on-the-Individual-Shared-Responsibility-Provision
Nick
@Guy:
Great. Thank you.
gelfling545
A large problem for people who get Medicaid is the twice annual recertification since it’s based not on annual income but a few pay checks so if they get a few overtime checks they’re out. This creates a problem of interrupted medical care for the working poor. I can see how this might create massive confusion with people having to move into & out of the exchanges with no secure medical coverage for long periods of time since I don’t expect processing times would be short. Is there any mechanism to deal with this kind of thing built into the ACA?
Pen
This is all well and good and, as much as I support the goals of the ACA I can’t use it. Why? Because of the two hospital franchises in my city only one is halfway competent and my wife’s part time job has work-offered “insurance” doesn’t cover the good hospital. I used to have my own work insurance that did, and that’s where our family goes. But, because of my wife’s employers offer Something My family can’t qualify for the subsidized public rates.
Knight of Nothing
Mr Mayhew and/or Balloon-Juicers – I have a question that perhaps you could answer or point me in the right direction. My cousin and her husband run a small but successful real estate business. She has been ranting nonstop about Obamacare in the last few weeks. She is a member of Blue Cross/Blue Shield MN, and she’s complained that they have raised her high-deductible rates by 23% to over $1100/month. In short, ACA has apparently made her position worse. I suspect that she may be SoL as she is one of the few for whom ACA is not meant. But are there any remedies for her? If I told her, “go look at the MN Exchange and see if there are better plans/rates?” would I be sending her on a fool’s errand? Does she have any other options?
Pen
This is all well and good and, as much as I support the goals of the ACA I can’t use it. Why? Because of the two hospital franchises in my city only one is halfway competent and my wife’s part time job has work-offered plan that doesn’t cover the good hospital. I used to have my own work plan that did and that’s where our family goes. But, because of my wife’s employer offers a minimum something, my family can’t qualify for the subsidized public rates.
Bloody typical. This is a step in here right direction, but it looks like, for the foreseeable future, I’m stick in our old feudal serf model.
Guy
@Knight of Nothing: Definitely refer her to the exchange. You did not mention if they have kids, but if it is just the two of them, $1100 seems way too high for a high deductible plan. Here in NC there are several BCBS “bronze” plans much less than that for a couple in their, say, mid-forties, and we are supposedly one of most expensive states under ACA.
Robert Sneddon
I’m British, I don’t have a dog in this fight but I’m continually boggled by the amount of confusing bullshit paperwork the PPACA introduces into folks lives in the US, and that’s me recognising it’s a vast improvement over the existing medical coverage situation for most American citizens.
A lot of commentators here and elsewhere piss on the British NHS from a great height, citing the Swiss or the French or Australian system of compulsory private insurance as so much better… and then mention the co-pays for visits to a doctor, the extra monthly insurance payments, the bullshit paperwork those “superior” systems require along with their bullshit administrative costs.
The NHS has no bullshit paperwork. Everybody is covered. There are no co-pays. There are no monthly insurance contributions. There are no qualifying events, enrollment crap, deductibles, age limits, income limits etc. because everybody is covered. There aren’t even any bills for pharmaceuticals now, all prescriptions are free (at least here in Scotland where I live, England is going that way real soon now while continuing with the current £7 per prescription fixed fee).
By the way, why do people here make comments about doctors not making home visits any more? Is that true in the US? If so how do housebound folks get treated or examined if they fall ill? Here it’s just a question of phoning the GP and arranging for the doctor to come round, usually the next morning before they start their surgery hours.
Steeplejack
@Knight of Nothing:
Bullshit. Sorry if I sound testy, but I am so sick of people (not you) complaining that Obamacare is causing their insurance to go up—which it has no doubt been doing all along, even before Obamacare was ever heard of—and then flailing in helpless, melodramatic “Wah! What can I do?!” mode without even taking the basic step of (as you point out) checking their options under the new law.
Based on your cousin’s demonstrated level of insight regarding Obamacare causing her insurance to go up, I don’t believe this either.
I don’t even live in Minnesota, but it was the work of but an instant to get to the MNCare site from HealthCare.gov and select the option for “small businesses” vs. “individuals or families.” I’m not going to go through the whole rigmarole of setting up an account, but it is clear from the page I landed on that there are numerous options available to help your cousin and her husband, including a link to “find an assister/broker” if they are so hapless that they can’t navigate a Web site. There is even a notice of a “special small business open enrollment” period from November 15 to December 15 “in which the participation and contribution requirements are waived.”
What businesses can use MNSure? “Businesses with 2-50 full-time-equivalent (FTE) employees (employees who work on average 30 hours/week or more or 130 hours or more per month) can enroll and offer coverage through MNsure.” Since you say your cousin has a “small but successful real estate business,” I would think that it qualifies.
It may be even simpler than that. Since your cousin and her husband appear to be self-employed, I believe they could also get an individual/family policy through MNCare.
In either case, I would be extremely surprised if they couldn’t get better coverage than what they have now at a lower cost.
Matt McIrvin
@Robert Sneddon:
That’s the amazing thing. The amount of confusing bullshit paperwork about health insurance that Americans had to deal with even under the previous circumstances is more than you can imagine. And much of it was designed to somehow deny them coverage.
Steeplejack
@Knight of Nothing:
To add to my previous post and fully vent my rage gland:
This is getting into the area of pathological “learned helplessness.” The exchanges are probably the greatest invention in the entire history of shopping for health insurance. End of story. If your cousin and her husband really need “other options” beyond that—and without even checking the exchange first—I would just back away slowly while offering my condolences that they won’t be able to vote for Michele Bachmann any more, since she is retiring.
Matt McIrvin
…Note, all the stuff that Richard is describing above isn’t any kind of special feature of the PPACA, it’s how health insurance plans work here.
Knight of Nothing
@Guy:
She does have kids. I probably should suggest that she check it out.
@Steeplejack:
Oh, I know. When I hear some of these complaints, I get agitated to the point that I’m pretty ineffective at making any sort of cogent reply. Two things are pretty obvious to people who aren’t busy demagoguing about ACA: 1) insurance costs have been going up for a long time, and 2) companies are using “Obamacare” as an opportunistic excuse to drop coverage, change terms of employment, or raise rates, whether or not that excuse is valid.
I also clicked through the MNSure site and got to the information you cite, but I didn’t want to sign up either. I was wondering if anyone had, if anyone is in a similar situation, or if anyone happens to know through a professional capacity. Like you, I strongly suspect that there are in fact better plans and lower rates for her and family, but I was hoping to tell her definitively.
Seems like she should take the time to investigate for herself.
Thanks both of you for your replies!
Matt McIrvin
Strangely, here in blue blue Massachusetts which has had ACA-like exchanges for years, the Obamacare-induced changes to my employer-provided health insurance happened many months ago, and… they were by and large modest improvements.
I suspect that’s what you get when your employer is being honest.
Knight of Nothing
@Steeplejack: yeah, shopping for insurance sucks, changing bank accounts sucks, going to the dentist sucks, so do a lot of things that we grown-ups all have to do.
I completely agree: the exchanges seem great, and the pity party is boring and pointless! As much as I’d like to tell her to get a grip, in this case, I’d rather play the role of gently coaxing her back to reality. She is family, after all :)
Betty Cracker
@Robert Sneddon:
House calls are almost unheard of here, though I’ve read about them making a come-back in some cities. It’s still rare enough to warrant a news article. Housebound folks are conveyed to a hospital at maximum expense to see a doctor or else treated at home by a home health nurse if that’s covered under their insurance and they have established that they have a chronic illness that requires it.
Our insurance system is so monumentally fucked up that I’m sure people who aren’t subject to its horrors must gape in amazement at the abject stupidity. The ACA won’t make that go away, but it’s at least a step in the right direction, inasmuch as it implies for the first time ever that there’s an obligation to provide everyone with coverage. I’m afraid those of us old enough to manipulate keyboards today will be long dead by the time there’s an actual, rational, universal healthcare delivery system in place such as that enjoyed in the UK.
Ruckus
@Matt McIrvin:
The VA works the same way. There is some paperwork however. They give me a printout of my appointments whenever I ask. And once a year I have to fill out a simple form to see if I still qualify due to income. Takes a minute or two at most.
Stupid socialized, government interfering medicine. How nice it is.
smedley the uncertain
As a Federal employee and retiree I’ve been living with Open Season for some 40 plus years. Each year I’m offered a brochure listing the most relevant insurance offerings for my region and nationally. I review and make a choice, or do nothing and continue with the current plan. There is a window every Nov/Dec within which to choose. This includes mid-season changes for relocation and family changes. A truly successful government operation. ACA seems to follow a very similar model.
Ryan G
If that’s the situation for enrollment, I expect that a lot of people with bare-bones coverage who get major illnesses marry each other the next day.
Sounds like a sitcom pitch.
Princess Leia
Just wondered if people with low income (but financial assets) are only eligible for medicaid and not able to purchase another plan. When I have tried to use the site to buy a platinum plan, it won’t let me do it unless I put in that I have a higher income. Advice?
Mnemosyne
@Knight of Nothing:
It’s kind of a meme on the right at the moment that Obamacare “made things worse!” because people are finding out that their crappy do-nothing insurance policies have been switched. Digby (who is on the left) got a similar letter from her insurance company but, since she has more than two brain cells to rub together, she immediately went to the California exchanges and discovered that she can get a better policy at lower cost than her current one, so she’s probably going to switch companies.
The Minnesota exchanges have some of the best rates in the country so if your cousin refuses to even look at them, she’s deliberately cutting off her nose to spite her face. If she decides she wants to pay more out of “principle,” that’s her decision, but you should probably try to make it clear to her that she has chosen to spend that extra money when she could have saved money by buying through the exchanges.
Mnemosyne
@Princess Leia:
What state are you in? Functioning (mostly blue) states should have health advocates available for you to talk to and walk you through the exchanges. If you’re in a non-functioning state (aka one with a Republican governor and/or legislature), you may have to try and track down a phone number at healthcare.gov to see if there’s a federal exchanges person you can talk to.
Knight of Nothing
@Mnemosyne: I just got this response from her:
I suspect that this isn’t the whole story, but I don’t have any actual data or any way of knowing.
Steeplejack
@Knight of Nothing:
Sorry, that sounds like more bullshit to me. Your cousin said she had a “high-deductible” plan now for which she pays $1,100 a month. I find it hard to believe that the “crappy bronze plan” is that much and/or offers worse coverage. Maybe she’s not factoring in the subsidy she would get?
Like I said before, back away slowly, etc. It sounds like your cousin is determined for this not to work, for whatever reason.
Knight of Nothing
@Steeplejack: yeah, you’re probably right – though I suspect that there will be a “eureka” moment in the next month or so that goes unheralded in the magic social media machines, in which she finds a suitable and affordable replacement for her current plan.