71.03 Special enrollment periods (SEP)134

General requirements135 AHS will provide SEP consistent with this subsection, during which qualified individuals may enroll in QHPs and enrollees may change QHPs. For the purpose of this subsection, “dependent” has the same meaning as it does in 26 CFR § 54.9801-2, referring to any individual who is or who may become eligible for coverage under the terms of a QHP because of a relationship to a qualified individual or enrollee. The requirement to have coverage in the 60 days prior to a triggering event is met if the qualified individual either had minimum essential coverage as described in § 23.00 for one or more days during the 60 days preceding the date of the triggering event; lived in a foreign country or in a United States territory for one or more days during the 60 days preceding the date of the triggering event; or meets other criteria established under federal law.136 (b) Effective dates137 Regular effective dates. Except as specified in paragraphs (b)(2) and (3) of this subsection, for a QHP selection received by AHS from a qualified individual, the coverage effective date will be the first day of the month following the QHP selection. Special effective dates (i) In the case of birth, adoption, placement for adoption, or placement in foster care, coverage is effective for a qualified individual or enrollee on the date of birth, adoption, placement for adoption, or placement in foster care or, if elected by the qualified individual or enrollee, in accordance with paragraph (b)(1) of this subsection. (ii) [Reserved] (iii) In the case of a qualified individual or enrollee eligible for a special enrollment period as described in paragraphs (d)(4), (d)(5), (d)(9), (d)(10), (d)(11), (d)(12), or (d)(13) of this subsection, coverage is effective on an appropriate date based on the circumstances of the special enrollment period. 134 45 CFR § 155.420. 135 45 CFR § 155.420. 136 See, e.g., 45 CFR §§ 155.420(a)(5) and 155.420(d)(6)(iv). 137 45 CFR § 155.420(b). Eligibility-and-Enrollment Procedures Part 7 – Page 60 (Sec.71.00, Sub.71.03) The effective date for a coverage change that is retroactive must be identified within a reasonable timeframe and is subject to QHP issuer review. (iv) In a case where an individual, enrollee or dependent, as applicable, selects a QHP on or before the date of the triggering event in accordance with the advanced availability described in paragraph (c)(2) of this subsection, the coverage effective date is the first day of the month following the date of the triggering event. If the plan selection is made after the date of the triggering event, the coverage effective date is the first day of the following month. Notwithstanding the requirements of this subsection, with respect to losses of coverage as described in paragraph (d)(1), (d)(6)(iii) and (d)(16) of this subsection, if the plan selection is made after the date of the triggering event, AHS will provide a coverage effective date that is the first day of the month following the date of the triggering event. (v) In the case of a court order as described in paragraph (d)(2)(i) of this subsection, coverage is effective for a qualified individual or enrollee on the date the court order is effective. Option for earlier effective dates (i) For a QHP selection received by AHS under a special enrollment period for which effective dates specified in paragraphs (1) and (2) of this section would apply, AHS may provide a coverage effective date that is earlier than specified in such paragraphs. (ii) At the option of a qualified individual, enrollee, or dependent who is eligible to select a plan during a period provided for under paragraph (c)(4) of this section, AHS will provide the earliest effective date that would have been available under this paragraph (b) of this section, based on the applicable triggering event under paragraph (d) of this section. APTC and CSR. Notwithstanding the standards of this subsection, APTC, Vermont Premium Reduction and federal and state CSR will adhere to the effective dates specified in § 73.06. (c) Availability and length of SEP138 General rule. Unless specifically stated otherwise herein, a qualified individual or enrollee has 60 days from the date of a triggering event to select a QHP. Advanced availability. A qualified individual or their dependent who is described in one of the following paragraphs of this subsection has 60 days before and after the date of the triggering event to select a QHP: (i) (d)(1); (ii) (d)(3) if they become newly eligible for enrollment in a QHP through VHC because they newly satisfy the requirements under § 19.01; 138 45 CFR § 155.420(c). Eligibility-and-Enrollment Procedures Part 7 – Page 61 (Sec.71.00, Sub.71.03) (iii) (d)(6)(iii); (iv) (d)(7); or (v) (d)(16). Special rule. In the case of a qualified individual or enrollee who is eligible for an SEP as described in paragraphs (d)(4), (d)(5), or (d)(9) of this subsection, AHS may define the length of the SEP as appropriate based on the circumstances of the SEP, but in no event will the length of the SEP exceed 60 days. Availability for individuals who did not receive timely notice of triggering events. If a qualified individual, enrollee, or dependent did not receive timely notice of an event that triggers eligibility for a special enrollment period under this section, and otherwise was reasonably unaware that a triggering event described in paragraph (d) of this section occurred, AHS will allow the qualified individual, enrollee, or when applicable, their dependent to select a new plan within 60 days of the date that they knew, or reasonably should have known, of the occurrence of the triggering event. (d) SEPs.139 AHS will allow a qualified individual or enrollee, and, when specified below, their dependent, to enroll in or change from one QHP to another if one of the following triggering events occur: The qualified individual or their dependent either: (i) Loses MEC. The date of the loss of coverage is the last day the individual would have coverage under their previous plan or coverage; (ii) Is enrolled in any non-calendar year group health plan, individual health insurance coverage, or qualified small employer health reimbursement arrangement (as defined in § 9831(d)(2) of the Code); even if the qualified individual or their dependent has the option to renew or re-enroll in such coverage. The date of the loss of coverage is the last day of the plan year; or (iii) Loses medically needy coverage only once per calendar year. The date of the loss of coverage is the last day the individual would have medically needy coverage. Gain or loss of dependent (i) The qualified individual gains a dependent or becomes a dependent through marriage, birth, adoption, placement for adoption, or placement in foster care, or through a child support order or other court order.140 In the case of marriage, at least one spouse must have had coverage for one or more days during the 60 days preceding the date of marriage, as described in paragraph (a)(3) of this subsection. (ii) The enrollee loses a dependent or is no longer considered a dependent through divorce or legal 139 45 CFR § 155.420(d). 140 See, 8 VSA § 4058. Eligibility-and-Enrollment Procedures Part 7 – Page 62 (Sec.71.00, Sub.71.03) separation as defined by state law in the state in which the divorce or legal separation occurs, or if the enrollee or their dependent dies. The qualified individual, or their dependent, becomes newly eligible for enrollment in a QHP through VHC because they newly satisfy the requirements under § 17.02 (citizenship, status as a national, lawful presence) or § 19.01 (incarceration); The qualified individual's or their dependent's enrollment or non-enrollment in a QHP is unintentional, inadvertent, or erroneous and is the result of the error, misrepresentation, misconduct or inaction of an officer, employee, or agent of AHS or HHS, its instrumentalities, or an individual or entity authorized by AHS to provide enrollment assistance or conduct enrollment activities, as evaluated and determined by AHS. For purposes of this provision, misconduct includes, but is not limited to, the failure to comply with applicable standards under this rule or other applicable federal or state laws, as determined by AHS. In such cases, AHS may take such action as may be necessary to correct or eliminate the effects of such error, misrepresentation, misconduct or inaction. See § 76.00(e)(3) regarding correction of an erroneous termination or cancellation of coverage; The enrollee or their dependent adequately demonstrates to AHS that the QHP in which they are enrolled substantially violated a material provision of its contract in relation to the enrollee; Newly eligible or ineligible for APTC, or change in eligibility for CSR (i) The enrollee is determined newly eligible or newly ineligible for APTC or has a change in eligibility for CSR; (ii) The enrollee's dependent enrolled in the same plan is determined newly eligible or newly ineligible for APTC or has a change in eligibility for CSR; or (iii) A qualified individual or their dependent who is enrolled in an eligible employer-sponsored plan is determined newly eligible for APTC based in part on a finding that such individual is ineligible for qualifying coverage in an eligible-employer sponsored plan, including as a result of their employer discontinuing or changing available coverage within the next 60 days, provided that such individual is allowed to terminate existing coverage. (iv) For purposes of subsections (i) and (ii), enrollee includes an individual enrolled in a qualified health plan or reflective health benefit plan141 directly through a QHP issuer.142 The qualified individual or enrollee, or their dependent, gains access to new QHPs as a result of a permanent move and had coverage for one or more days during the 60 days preceding the date of the permanent move, as described in paragraph (a)(3) of this subsection. The qualified individual: 141 See, 33 VSA § 1813. 142 See, 45 CFR § 155.420(d)(6)(v). Eligibility-and-Enrollment Procedures Part 7 – Page 63 (Sec.71.00, Sub.71.03) (i) Who gains or maintains status as an Indian, as defined by § 4 of the Indian Health Care Improvement Act, may enroll in a QHP or change from one QHP to another one time per month; or (ii) Who is or becomes a dependent of an Indian, as defined by § 4 of the Indian Health Care Improvement Act and is enrolled or is enrolling in a QHP through VHC on the same application as the Indian, may change from one QHP to another one time per month, at the same time as the Indian; The qualified individual or enrollee, or their dependent, demonstrates to AHS, in accordance with guidelines issued by HHS, that the individual meets other exceptional circumstances as AHS may provide.143 The qualified individual or enrollee is a victim of domestic abuse or spousal abandonment as described in § 12.03(b). This special enrollment period is available to any member of a household who is a victim of domestic abuse, including unmarried and dependent victims within the household, as well as victims of spousal abandonment, including their dependents. The qualified individual or their dependent applies for coverage during the AOEP or due to a triggering event, is assessed as potentially eligible for Medicaid, and is determined ineligible for Medicaid either after the AOEP has ended or more than 60 days after the triggering event. The enrollment in a QHP through VHC was influenced by a material error related to plan benefits, service area, or premium. A material error is one that is likely to have influenced a qualified individual’s, enrollee’s, or their dependent’s enrollment in a QHP. The qualified individual provides satisfactory documentary evidence to verify their eligibility for enrollment in a QHP through VHC following termination of enrollment due to a failure to verify such status within the time period specified in § 57.00(c)(2)(ii).144 The qualified individual, who is not an enrollee, becomes pregnant. Any individual who is eligible for coverage under the terms of the health benefit plan because of a relationship to the pregnant individual may enroll through this SEP provided the pregnant individual does so. This SEP is available at any time after the commencement of the pregnancy for the duration of the pregnancy.145 The qualified individual is in possession of a certificate of exemption as described in § 23.06 and (i) Is notified by HHS that they are no longer eligible for the exemption; or (ii) Is eligible for enrollment in a QHP that is a catastrophic plan as described in § 14.00(b). When this triggering event occurs, the individual may only enroll in a catastrophic plan. 143 See Vermont Health Connect’s website for more information on these triggering events. 144 See, § 11.02 regarding QHP eligibility. 145 33 VSA § 1811(l). Eligibility-and-Enrollment Procedures Part 7 – Page 64 (Sec.71.00, Sub.71.03) Loss of assistance paying for COBRA (i) The qualified individual or their dependent is enrolled in COBRA continuation coverage146 for which an employer is paying all or part of the premiums, or for which a government entity is providing subsidies, and the employer completely ceases its contributions to the qualified individual’s or dependent’s COBRA continuation coverage or government subsidies completely cease. (ii) The triggering event is the last day of the period for which COBRA continuation coverage is paid for or subsidized, in whole or in part, by an employer or government entity. Eligibility for CSR Tier I or II (i) The qualified individual, or their dependent, is eligible for CSR Tier I or II, as defined in § 13.02. (ii) The enrollee, or their dependent, is eligible for CSR Tier I or II, as defined in § 13.02. Plan selection for the enrollee or their dependent will be limited to a silver level QHP. (e) Loss of coverage147 Loss of coverage described in paragraph (d)(1) of this subsection includes those circumstances described in paragraphs (d)(1)(ii) and (iii) of this subsection and in paragraphs (3)(i) through (iii) below. Loss of coverage does not include voluntary termination of coverage or other loss due to: (i) Failure to pay premiums on a timely basis, including COBRA continuation coverage premiums prior to expiration of COBRA continuation coverage, except for circumstances in which an employer completely ceases its contributions to COBRA continuation coverage, or government subsidies of COBRA continuation coverage completely cease as described in paragraph (d)(16) of this section; or (ii) Termination of an individual’s coverage for cause (which could include, but not be limited to, termination because of an action by the individual that constituted fraud or because the individual made an intentional misrepresentative of a material fact).148 Eligibility for COBRA when the qualified individual or their dependent loses coverage does not disqualify the individual or their dependent from a special enrollment period under this subsection. The following conditions also qualify an employee for a special enrollment period under (d)(1) of this 146 See, 45 CFR § 144.103. 147 45 CFR § 155.420(e). 148 See, 45 CFR § 147.128. Eligibility-and-Enrollment Procedures Part 7 – Page 65 (Sec.71.00, Sub.71.03) subsection:149 (i) Loss of eligibility for coverage. In the case of an employee or dependent who has coverage that is not COBRA continuation coverage, the conditions are satisfied at the time the coverage is terminated as a result of loss of eligibility. Loss of eligibility under this paragraph does not include a loss due to the failure of the employee or dependent to pay premiums on a timely basis or termination of coverage for cause (such as making a fraudulent claim or an intentional misrepresentation of a material fact in connection with the plan). Loss of eligibility for coverage under this paragraph includes (but is not limited to): Loss of eligibility for coverage as a result of legal separation, divorce, cessation of dependent status (such as attaining the maximum age to be eligible as a dependent child under the plan), death of an employee, termination of employment, reduction in the number of hours of employment, and any loss of eligibility for coverage after a period that is measured by reference to any of the foregoing; In the case of coverage offered through an HMO, or other arrangement, in the individual market that does not provide benefits to individuals who no longer reside, live or work in a service area, loss of coverage because an individual no longer resides, lives, or works in the service area (whether or not within the choice of the individual); In the case of coverage offered through an HMO, or other arrangement, in the group market that does not provide benefits to individuals who no longer reside, live or work in a service area, loss of coverage because an individual no longer resides, lives or works in the service area (whether or not within the choice of the individual), and no other benefit package is available to the individual; and A situation in which a plan no longer offers any benefits to the class of similarly situated individuals 150that includes the individual. (ii) Termination of employer contributions. In the case of an employee or dependent who has coverage that is not COBRA continuation coverage, the conditions are satisfied at the time employer contributions towards the employee’s or dependent’s coverage terminate. Employer contributions include contributions by any current or former employer that was contributing to coverage for the employee or dependent. (iii) Exhaustion of COBRA continuation coverage.151 In the case of an employee or dependent who has coverage that is COBRA continuation coverage, the conditions are satisfied at the time the COBRA continuation coverage is exhausted. An individual who satisfies the conditions of paragraph (e)(3)(i) of this subsection, does not enroll, and instead elects and exhausts COBRA continuation coverage satisfies the conditions of this paragraph. 149 26 CFR § 54.9801-6(a)(3)(i) through (iii). 150 See, 26 CFR § 54.9802-1(d). 151 See, also, 26 CFR § 54.9801-2. Eligibility-and-Enrollment Procedures Part 7 – Page 66 (Sec.72.00, Sub.73.01) Duration of QHP eligibility determinations without enrollment152 (01/01/2018, GCR 17- 048) To the extent that an individual who is determined eligible for enrollment in a QHP does not select a QHP within their enrollment period, or is not eligible for an enrollment period, in accordance with § 71.00, and seeks a new enrollment period prior to the date on which their eligibility is redetermined in accordance with § 75.00 (annual redetermination), AHS will require the individual to attest as to whether information affecting their eligibility has changed since their most recent eligibility determination before determining their eligibility for a special enrollment period, and will process any changes reported in accordance with the procedures specified in § 73.00 (mid-year redetermination). Eligibility redetermination during a benefit year153 (01/01/2024, GCR 23-087)