QHP & MAGI Medicaid – How & When to Apply

• Online through healthyrhode.ri.gov.
• Over the phone by calling the HSRI contact center – 1-855-840-4774
• In person:
• with a certified navigator (search available here);
• with a certified application counselor (list as of July 2015 available here); or
• at a DHS field office (list available here).  DHS field offices may just refer applicants to a self-service computer and provide little personalized assistance.
• By mail with the paper application (available here).  Paper applications are discouraged because processing times are slower than with other methods.

Every household that applies for coverage is given an online account.  One individual on the application is designated as the “head of household,” and this individual selects a username and password.  This account and login information can then be used in the future for many purposes.

If any information from a household’s application changes during the year, they must inform HSRI about the change.  The best ways to do so are via their online account, by calling the contact center, or visiting a navigator.  Some common reasons households must update their applications include:

• Changes in household size;
• Changes in income;
• Change in contact information

Information or Documents Needed For Application

Applicants must be prepared to provide the following information about themselves and all members of their household:

• Social Security numbers (for all who have them)
• Applicants who do not have a Social Security number can still apply.  They will not be eligible to receive MAGI Medicaid, but might be eligible to enroll into a QHP.
• Basic demographic information (names, birthdays, etc.)
• Income (for more details, see MAGI Medicaid – Income and APTC & CSR Eligibility – Income and Household Size)
• Immigration status and immigration document numbers (where relevant)
• Tax filing status
• Incarceration status

In addition, it is often helpful to have the following documents handy:

• Valid form of ID for each household member (e.g. driver’s license, passport, birth certificate)
• Most recent tax return / other tax information and documentation
• Income documentation from previous four weeks (potentially including pay stubs, Social Security award letter, unemployment documentation, etc.).
• Social Security cards of each household member who has one
• Immigration documents of each household member
• Incarceration release documentation
• Documents about current health insurance to which any member of household may have access
• Names of any doctors an applicant wants to keep, or prescriptions an applicant will need covered

These documents are not necessarily mandatory, but they can help ensure that accurate information is included on the application.  The documents can also sometimes be requested by the State for verification purposes (discussed below).

Application Process / ID Proofing

On the first page of the online application a username and password are created, some contact information is collected, and three security question are set up.  On the second page, the head of household inputs his Social Security number (if he has one), and date of birth.

It is extremely important to double-check that this initial information has been entered correctly.  Most information entered into an application can be easily changed, but it is very difficult to change Social Security numbers and dates of birth if entered incorrectly.

Once this information has been submitted, the next step is for HSRI to confirm that the applicant is who he says he is (called “identity proofing”).  At this point, two things may occur.  Either:

• The applicant is asked to answer a series of personal questions that he would know the answer to.  If the questions are answered correctly, then the applicant can proceed. or
• No questions are presented, and the applicant is instructed to call Experian and then HSRI to verify his identity.  This outcome is most comment for applicants with no credit history.  The call to Experian is rarely successful, so applicants at this point may want to call HSRI directly.  HSRI will then conduct a manual identity proofing over the phone by recording a verbal attestation.  Once successful, the application is unlocked and the applicant can proceed.

Verification

The final page of the online application requires the head of household (and his/her spouse when applicable) to sign the application electronically.  The application is then submitted, at which point HSRI verifies the information on the application against various State and Federal databases (e.g. IRS, Social Security, State Wage Data, etc.).

If verification works smoothly, then eligibility is determined within about a minute.  The applicant is then able to view health plan options for the household, choose a plan, and enroll.

However, sometimes the verification process results in requests for further documentation.  Common items requiring manual verification include:

• Income;
• Incarceration;
• Immigration Status / Citizenship
• Social Security Number
• Name
• Birth Date
• Death

Verification can often be provided through the documents listed above.  Documents can be scanned and uploaded to the online system, mailed to HSRI (to the address provided on the verification page), or dropped of at the HSRI contact center (70 Royal Little Drive, Providence).  HSRI will also send a letter requesting verification documents.

Verification for QHP Enrollment

For applicants who are eligible for QHP enrollment (based on the information provided by the applicant), the deadline for providing verification documents is 90 days.

During this 90-day verification period, HSRI must allow the applicant to enroll based on the information provided on the application.  In other words, HSRI must “take the applicant’s word for it” during this 90-day period.

Verification for Medicaid Enrollment

For applicants who are eligible for Medicaid (based on the information provided by the applicant), the deadline for providing verification documents is 10 days.

Eligibility for Medicaid benefits during the period before verification is complete depends on the eligibility factor that needs to be verified.  If the verification is related to citizenship or immigration status, then the applicant can receive benefits during this period.  If the verification is related to any other eligibility factor (e.g. income), then no benefits can be received until verification is completed based on the documents provided.

Purchasing a QHP through HSRI

Applicants eligible for a QHP must choose which QHP they would like to buy.  QHPs are currently offered by BlueCross BlueShield of RI, Neighborhood Health Plan of RI, and United Healthcare.  Each of these insurers offers several plans.

Once a household has selected a health insurance plan (and potentially dental plan), the applicant is prompted to pay the first month’s premium.  Payments can be made:

• online using an electronic funds transfer (EFT, or “e-check”),
• by mailing a check or money order to HSRI, P.O. Box 9711, Providence, RI 02940-9711, or
• by taking a check or money order and delivering it by hand to the HSRI contact center at 70 Royal Little Drive, Providence.

Credit card and cash payments are not currently accepted by HSRI.

Payments must generally be received on or before the 23rd of the month to receive coverage starting on the first of the following month.  The biggest exception occurs for January 1 start dates, when HSRI often relaxes this deadline.

EFTs are deemed to be paid on the day they are made.  When mailing checks, applicants should take mailing time into account.

More information on payment options and deadlines can be found in this article.

Choosing a Medicaid Plan

Applicants eligible for Medicaid also must choose plan.  There are only two options:  one plan from Neighborhood and one from United.  These plans are nearly identical in terms of their benefits and coverage.

Timing

The time needed to complete an application varies from about 20 minutes to a few hours, depending on complexity.  Factors that tend to make the process take longer include: larger household size, multiple sources of income, verification processes, and wait times on the phone if a call to the call center is required.

It is always best to start the process early and avoid waiting until the last minute.

Health Plan ID Cards

The health plan ID cards are mailed by the insurance companies themselves, not by HSRI of the State.  It normally takes about two weeks to receive a card and welcome package in the mail.  For some applicants, this will mean not having an ID before the coverage is active.

QHP Open Enrollment Period

Applicants are only able to enroll into a QHP or change QHPs during an Open Enrollment or Special Enrollment Period.  For the 2016 plan year, the Open Enrollment Period will take place from November 1, 2015 through January 31, 2016.

(For Medicaid, eligible applicants can enroll at any time of year.)

Example 1
In the middle of August, Mike is uninsured.  His income is too high for Medicaid, and he has not had any recent life changes that would give him access to an SEP (see below).
→ Mike cannot enroll into coverage until the next open enrollment period.

Applicants eligible for Medicaid can get covered at any time of year.  They need not wait for open or special enrollment periods.

QHP Special Enrollment Periods

Outside of Open Enrollment Periods, applicants can enroll into a QHP or change QHPs only if they have a Special Enrollment Period (SEP).  SEPs are typically triggered by changes in life circumstances.

There are eight SEP triggers that allow an applicant to enroll into a QHP or change QHPs outside of Open Enrollment.  There are also two additional SEPs that only allow current enrollees to change QHPs, but would not allow a new enrollment.

SEPs Allowing Enrollment or Change of QHPs

• Loss of other coverage – the individual or his or her dependent losses minimum essential coverage, for example after the loss of a job.  A voluntary termination of coverage, or a loss of coverage for failure to pay premiums, does not trigger an SEP.
• Family changes – the individual gains a dependent or becomes a dependent through marriage, birth, adoption, placement for adoption, place in foster care, or through a child support order or other court order.
• Change in immigration status – the individual or his dependent becomes newly eligible for QHP enrollment based on a change immigration status (see here for more details on qualifying immigration status).
• HSRI mistake – the individual’s or her dependent’s enrollment or non-enrollment in a QHP was unintentional, inadvertent, or erroneous, and is the result of an error, misrepresentation, misconduct, or inaction of HSRI or one of its contractors providing enrollment services.
• Move – the individual moves into Rhode Island.
• Change in Affordability of Enrolled Employer Coverage – the individual or his dependent who is enrolled in an employer-sponsored plan is determined newly eligible for APTCs based on a new determination that the employer plan is not affordable (for more on affordability, see here), including as a result of a discontinuance of or change to the employer plan, provided the individual is allowed to terminate the employer plan coverage.
• Indian / Native American – individuals who meet a federal definition of “Indian” may enroll in a QHP or change QHPs at any time during the year, up to once per month.
• Exceptional circumstances – the individual demonstrates to HSRI that exceptional circumstances warrant the granting of an SEP.

SEPs Allowing Enrollees to Change QHPs

• Insurance company misconduct – the enrollee or his dependent demonstrates that the QHP in which he is enrolled substantially violated a material provision of its contract in relation to the enrollee.
• Newly eligible for advanced premium tax credits (APTCs) or changed eligibility for cost-sharing reductions (CSRs) – the enrollee or her dependent becomes newly eligible for APTCs or has a change in eligibility for CSRs.  A household would typically become newly eligible for APTCs when their projected annual income drops below 400% of FPL (though it could happen at other income levels).  Eligibility for CSRs changes at 150%, 200%, and 250% of FPL.

Example 2
John and Maria are married and uninsured.  They have a new baby in July.
→ John, Maria, and the baby are all eligible for a special enrollment period starting from the date of birth of the baby.

Example 3
Steve and Melissa are married.  Until July, Steve had coverage through his job, but there was no option of covering dependents.  Melissa works too, but had no coverage at her job.  She has been covered through HSRI.  In July, Steve lost his job, and his job-based coverage ended at the end of the month.  The family’s income decreased, but it was still too high for Medicaid.
→ Steve has an SEP because he lost his other coverage.  Melissa also has an SEP because her “dependent” (Steve) lost his other coverage.  (“Dependent” is defined for these purposes as anyone who would have access to enroll into a QHP with an individual by virtue of a relationship to that individual.)  

Applicants eligible for Medicaid can get covered at any time of year.  They need not wait for open or special enrollment periods.

Length of SEP

SEPs generally last for 60 days, starting from the date of the triggering event.

For SEPs triggered by the loss of other coverage (item 1 from the first SEP list above), or by a change in affordability of employer sponsored coverage (item 6 from the first SEP list above), the individual may also select a new QHP up to 60 days before the triggering event.  (As of Jan. 1, 2017, HSRI must also allow this pre-event enrollment option to those moving in from out of State.  HSRI may elect to implement this change sooner.)

For SEPs triggered by an HSRI error (item 4 from the first SEP list), insurance company misconduct (item 1 from the second SEP list), or exceptional circumstances (item 8 from the first SEP list), HSRI may allow for an SEP of more than 60 days, as appropriate based on the circumstances.

QHP Effective Dates of Enrollment

In general, an HSRI applicant must complete the application, choose a plan, and pay the first month’s premium on or before the 23rd of a month in order for coverage to be effective on the 1st of the following month.

During Open Enrollment, many applicants’ coverage cannot be effective until January 1st of the coverage year, even if they complete all their steps in November or early December.

For the end of Open Enrollment, HSRI has often made exceptions from their typical deadline of the 23rd of the month, allowing applicants to choose plans after that date, and even allowing January 1 start dates for people paying their first premium in early January.  These policies often shift as the deadline approaches, so stay tuned for updates.

For SEPs, the general rule is the same.  Applicants are covered from the 1st of a month if they have completed the application, chosen a plan, and paid the first month’s premium on or before the 23rd of the prior month.  But there are some exceptions to this rule for certain SEPs:

• Loss of Coverage – When an individual loses other coverage, HSRI must ensure that QHP coverage is effective as of the first day of the month following the loss of coverage.
• Move – When an individual uses an SEP based on permanently moving to RI, the coverage is effective as of the first day of the month following the move.
• Birth – In the case of birth, adoption, placement for adoption, or placement in foster care, HSRI must ensure that coverage is effective as of the date of the birth, adoption, placement for adoption, or placement in foster care.  HSRI may also allow the applicant to opt for coverage to be effective as of the first of the month following the birth, adoption, placement for adoption, or placement in foster care.
• Marriage – In the case of marriage, HSRI must ensure that coverage is effective as of the first day of the month following the marriage.
• Death – HSRI must ensure that coverage for the surviving family members is effective on the first day of the month following plan selection (even if that occurred after the 23rd of the month).  HSRI may also allow such individuals to select a standard enrollment effective date.
• Special Circumstances – In the case of an SEP based on an HSRI mistake, insurance company misconduct, or other exceptional circumstances, HSRI must exercise discretion and ensure that coverage is effective as of an “appropriate” date based on the circumstances.
• Court Order – When an SEP is triggered by an individual gaining a dependent or becoming a dependent as the result of a court order, HSRI must ensure that the coverage is effective as of the effective date of the court order.  HSRI may also allow the applicant to opt for coverage to be effective in accordance with its typical rules.

For the circumstances listed above when someone’s coverage may start in the middle of a month (e.g. birth), the APTC can only become effective as of the first of the following month.

Example 4
Consider example 2 above, where John and Maria have a baby in July.  They choose a plan and pay their first premium during August.
→ Their coverage will be effective as of the birthday of the child.  HSRI may also permit John and Maria to choose to have their coverage and their baby’s coverage become effective as of August 1st, the first day of the month following the birth.

Example 5
Consider example 3 above, where Steve lost his work-based coverage as of July 31.  They applied, chose a plan, and paid their first premium on September 6th.
→ Their new QHP coverage will be effective as of August 1, the day following the loss of Steve’s job-based coverage.  They have no option of starting coverage on a later date.  (This means that they may owe back premiums very quickly.)

Medicaid Effective Dates of Coverage

MAGI Medicaid coverage is effective as of the first day of the month in which the application was submitted.  This means for someone who applies on July 24th, for example, Medicaid coverage would be effective as of July 1.

The coverage through the Medicaid health plan (Neighborhood or United) may not be effective until a month or two later.  During the interim period (between the coverage effective date and the plan effective date), the applicant has Medicaid “fee-for-service” coverage.

More Resources

• 45 C.F.R. § 155.410 (federal regulation on open enrollment period)
• 45 C.F.R. § 155.420 (federal regulation on special enrollment periods)
• EOHHS Rule 1308 (State rule on verification for Medicaid eligibility, including lists of acceptable verification documents)
• HSRI Draft Policy and Procedures Manual (Chapter 3)
• HSRI Paper Application
• HSRI Navigator Search Tool
• List of Certified Application Counselors (as of July 2015)
• List of DHS Field Offices
• www.healthcare.gov/coverage-outside-open-enrollment/special-enrollment-period/