Are Your HIV Program Clients Eligible for a Special Enrollment Period?

Content From: TargetHIVPublished: May 14, 20203 min read


Cross-posted from TargetHIVExit Disclaimer

Affordable Care Enrollment TA Center

Note: Since many Americans have experienced job losses due to COVID-19 that may have also affected their health coverage, we are sharing this information for HIV case managers, benefits coordinators, and program administrators.

In these uncertain times, people with HIV may be experiencing job losses or other unexpected income or life changes. Remind your clients that they may be able to get covered or stay covered with Marketplace or off-Marketplace health insurance through a Special Enrollment Period (SEP). Some clients may also be newly eligible for Medicaid or Children’s Health Insurance Program (CHIP).

There are many life events and special circumstances that create Special Enrollment Periods

People who lose employer-based health coverage because of a change in job status are eligible for the “loss of coverage” SEP. This SEP also applies for people who lose their employer coverage because their work hours have been reduced, or because their employer is now contributing less (or nothing at all) to the premium amount. This SEP also applies when a spouse has lost employer-based health coverage.

There are many other qualifying events that create Special Enrollment Periods, including common life events and special circumstances. Check out the Health Resources and Service Administration’s HIV/AIDS Bureau (HRSA HAB) funded ACE TA Center’s Special Enrollment Periods Consumer Fact SheetExit Disclaimer for details.

Clients may be eligible for comprehensive health coverage through the Marketplace, or through off-Marketplace plans, Medicaid, or Medicare

Remember that the Ryan White HIV/AIDS Program (RWHAP) is not health insurance. Whenever possible, help your clients find affordable plans that provide comprehensive health coverage.

  • Help your clients explore health insurance through Marketplace or off-Marketplace options. In many states, the RWHAP (including ADAP) may be able to pay premiums, or may purchase unsubsidized plans for some clients. These options are available in many states, whether or not they have expanded Medicaid
  • In states that have expanded Medicaid, some clients may also become newly eligible for Medicaid due to reduced income. Medicaid and CHIP enrollment are open all year long.
  • Eligible clients that are turning 65 should enroll in Medicare if they do not have employer coverage. For more, watch a replay of the ACE TA Center’s April 22 webinar: The Basics of Medicare for Ryan White HIV/AIDS Program ClientsExit Disclaimer.

Access to health coverage for COVID-19 related health concerns

Medicare and all group health insurance plans (including Marketplace and off-Marketplace plans) are required to cover COVID-19 testing without cost-sharing, such as deductibles, co-pays, and coinsurance. However, services that are not directly related to testing, (such as other testing or treatment provided during the same appointment, or COVID-19 treatment and hospitalization), may be subject to cost-sharing. Many state Medicaid programs are issuing similar notices.

Note: Short-term limited duration plans are not considered insurance. Therefore they may not be required to cover COVID-19 related testing.

State-specific SEP updates

In addition, 12 states (CA, CO, CT, ID, MD, MA, MN, NV, NY, RI, VT and WA) and Washington, D.C. that run their own marketplaces have established SEPs because of the COVID-19 emergency. In these states, anyone can enroll in or change coverage even if they have not experienced another qualifying event. (Note: Idaho's SEP is open to individuals who have recently lost employer-sponsored health insurance, not to previously uninsured individuals.) Depending on the state, the SEP may end in April, May, or June. If your state has been crossed out in the list above, their SEP has already ended. To see the full list and details about what is happening in each state, check with your state’s marketplace, or see this interactive mapExit Disclaimer from the Kaiser Family Foundation.

Reminder: HRSA HAB continues to update its list of Coronavirus 2019 (COVID-19) Frequently Asked Questions (FAQs) and resources for RWHAP recipients, subrecipients, and stakeholders.