Obamacare New York Special Enrollment Period (plan, hospital, coverage, benefits)

[Forest_Hills_Daddy]

Patient I know of missed the New York open enrollment period because he had to take care of a sick spouse overseas (he is a recent green card awardee, spouse is not). Can he qualify for the special enrollment period? Reason why he cannot wait for the next open enrollment is because while abroad he found out he had cancer.

[Qwerty]

Possibly-depends on when he got his green card and was eligible to sign up for health care. If he is still within 30 days, he probably can. He can always sign up for an off-marketplace plan (individual plan) outside of the open enrollment period. There just won't be any subsidies, which only matters if he is eligible for subsidies.

[Inquring81]

Originally Posted by Forest_Hills_Daddy

Patient I know of missed the New York open enrollment period because he had to take care of a sick spouse overseas (he is a recent green card awardee, spouse is not). Can he qualify for the special enrollment period? Reason why he cannot wait for the next open enrollment is because while abroad he found out he had cancer.

1. Special Enrollment Periods are 60 days long -- if he just got his green card, 60 days from that date, his Special Enrollment Period closes. There are a fairly small number of reasons that someone can get a Special Enrollment Window.

2. If his income is above 150% of the Federal Poverty level, the only other (relatively) easy way of qualifying for a Special Enrollment Window would be to move to a different county of New York. If you permanently move to a different county, you are entitled to another Special Enrollment Window of 60 days.

3. How much is his income? I don't know if the New York State of Health (NYS Marketplace) would consider a spouse overseas part of his household, but it's worth calling them to ask.

4. Depending on his age and income level, there are a few programs in New York State that you can enroll in all year long.

NYS Medicaid -- He could apply for Medicaid if he is a) over 65; under 18; blind; on disability; or the caretaker of a child under 18, he can qualify for Medicaid if his income is below 80% of the Federal Poverty Level and he's got less than $14,800 in assets. Here's the new Federal Poverty Limits for 2016: https://aspe.hhs.gov/poverty-guidelines

5. On the other hand if he is over 18, but under 65, can see, is not on disability and isn't taking care of any children under 18, he can have NYS Medicaid if he has an have an income of up to 138% of the Federal Poverty Level and doesn't have to worry about any asset limits.http://www.health.ny.gov/health_care/medicaid/#qualify

6. NYS Essential Plan -- This is essentially the benefits of Medicaid, but for people who are just over the Medicaid income levels. There are two levels of Essential plan, tied to income:

Level 1: Income between 138% - 150% of Federal Poverty Level - Free, no cost coverage.
Level 2: Income between 150% and 200% of Federal Poverty Level - $20 a month premium
Here's the link for more info: http://info.nystateofhealth.ny.gov/EssentialPlan

7. Child Health Plus: Has to be under 19 years of age and I forget the income level -- check it out here:http://www.health.ny.gov/health_care...y_and_cost.htm

8. If absolutely none of this helps, and he is living in New York City, the City hospitals have a sliding scale fee payment program called "HHC Options." He can go to any HHC facility and apply for it. But he will still owe the tax penalty for not having had comprehensive coverage in 2016.http://www.nychealthandhospitals.org...-Options.shtml

[Inquring81]

Originally Posted by Qwerty

Possibly-depends on when he got his green card and was eligible to sign up for health care. If he is still within 30 days, he probably can. He can always sign up for an off-marketplace plan (individual plan) outside of the open enrollment period. There just won't be any subsidies, which only matters if he is eligible for subsidies.

Qwerty:

I'd like to know more about the off-marketplace plans you're referencing here. Are these ACA compliant plans? Or the short-term non-ACA compliant ones that several posters have referenced?

In New York there are a number of insurance companies which offer coverage for sale directly to the consumer (without going to through the Marketplace). Some offer coverage both through the exchange and by purchasing directly off their websites, others do not participate in the Exchange, but are offering ACA quality coverage direct to the consumer. But as far as I know, all of these companies are following the same Open Enrollment periods as the Exchange. If it's after Open Enrollment has closed, and the client doesn't qualify for a Special Enrollment Period (and can prove it), it doesn't matter how much money they've got, they won't sell you a policy directly.

If there are other direct pay options that are offering comprehensive coverage, or if there is another workaround, would be very interested in hearing it.

[Forest_Hills_Daddy]

Originally Posted by Inquring81

NYS Medicaid -- He could apply for Medicaid if he is a) over 65; under 18; blind; on disability; or the caretaker of a child under 18, he can qualify for Medicaid if his income is below 80% of the Federal Poverty Level and he's got less than $14,800 in assets. Here's the new Federal Poverty Limits for 2016: https://aspe.hhs.gov/poverty-guidelines

5. On the other hand if he is over 18, but under 65, can see, is not on disability and isn't taking care of any children under 18, he can have NYS Medicaid if he has an have an income of up to 138% of the Federal Poverty Level and doesn't have to worry about any asset limits.Medicaid

6. NYS Essential Plan -- This is essentially the benefits of Medicaid, but for people who are just over the Medicaid income levels. There are two levels of Essential plan, tied to income:

Level 1: Income between 138% - 150% of Federal Poverty Level - Free, no cost coverage.
Level 2: Income between 150% and 200% of Federal Poverty Level - $20 a month premium
Here's the link for more info: Essential Plan Information | New York State of Health

8. If absolutely none of this helps, and he is living in New York City, the City hospitals have a sliding scale fee payment program called "HHC Options." He can go to any HHC facility and apply for it. But he will still owe the tax penalty for not having had comprehensive coverage in 2016.HHC Options

Thanks. I spoke to a lawyer. Lawyer advised that Medicaid is not a good option since the patient has assets overseas. If those assets are declared, patient will likely not qualify (and even if he does, state will try to put a lien on assets). If assets not declared, patient could be liable for fraud (most of the lawyer's medicaid clients are immigrants who did not disclose overseas assets/homes and now facing fraud charges). Lawyer suggested Obamacare and try to get an exception.

HHC is a good idea. Patient is hesitant about the quality of NYC-owned hospitals but cancer is localized so maybe it will be good enough.

[Inquring81]

You're welcome -- good luck!