We live in a world of instant gratification. You can order a pair of shoes on Amazon while waiting at a red light. You can have groceries delivered to your door in two hours. You can stream any movie ever made with the click of a button.
We have been trained to believe that we can buy whatever we want, exactly when we want it.
But the health insurance industry does not necessarily work that way.
It is one of the few industries left where you can stand with money in your hand and still be told "no" by health insurance companies.
This reality hits thousands of Texans every single year. They wake up in February or July and decide it is finally time to get health coverage. They log onto the computer. They get their credit card ready.
Then they realize there is no "Buy Now" button federally facilitated marketplace for ACA health insurance plans.
Let me tell you about Sarah. Sarah spent the last decade working a corporate job with great benefits in Austin.
She finally decided to take the leap and start her own consulting business. She was excited. She had her LLC formed. She had her first two clients signed. She was ready to be her own boss.
She left her corporate job in late February. She assumed she would just hop onto Healthcare.gov a few weeks later to pick up a plan. She figured she would take a month off from premiums to save some cash after leaving her job based plan.
Sarah sat down at her laptop in April to buy a policy. She needed to refill a prescription that was running low.
She navigated to the website. She created an account. And then she hit a brick wall. The system told her she was not eligible to enroll.
She panicked.
She called our office and got connected with Kevin. Her voice was panicked. She kept saying, "I have the money. I want to pay. Why won't they let me buy insurance?"
Kevin had to explain the hard truth to her. She had missed her special enrollment period window.
Insurance companies are terrified of one thing. They are terrified of "adverse selection."
That is a fancy industry term for a simple concept. They do not want people to wait until they are sick to buy insurance.
Imagine if you could buy car insurance after you crashed your truck. No one would pay premiums until something bad happened. We would all just drive around for free until we hit a telephone pole. Then we would call from the side of the road looking for minimum essential coverage.
Health coverage works the same way. If you could buy it anytime, healthy people would never pay. They would wait until the ambulance was on the way to the hospital to sign up for a health plan.
That would bankrupt the system overnight.
To combat this phenomenon, they created the Open Enrollment Period that you hear about each fall. It is that short window at the end of the year when anyone can buy anything.
Once it closes, the door to sign up for coverage is locked. The only way to unlock that door is with a special key called a Special Enrollment Period. And there are three key rules to unlocking the door.
Kevin explained to Sarah that she needed a Qualifying Life Event to unlock the door.
Think of this like a Golden Ticket from Willy Wonka. Without it, you do not get into the factory.
You cannot just decide you want insurance. "I realized I’m getting older" is not a qualifying event. "My knee started hurting" is not a qualifying event.
You need a life-changing moment.
The most common ticket is the loss of other coverage. This happens when you leave a job with benefits. It happens when you turn 26 and fall off your parents' plan. It happens when you get divorced and lose coverage from a spouse. There are other tickets too.
All of these are qualifying events. But Sarah had a problem. She did have a Golden Ticket when she left her job in February. But she had waited too long to use it after her qualifying life event.
This is where Sarah got caught in the trap.
When you have a Qualifying Life Event, a timer starts ticking. You generally have exactly 60 days from the date of the event to pick a new plan.
It is a strict enrollment deadline. There is no grace period. There is no appeal process if you just forget.
If you lose your job on June 1st, your clock runs out July 30th.
If you call us on day 58, Kevin can help you. We can get your application in and secure your coverage.
If you call us on day 61, Kevin has to give you the bad news. You are locked out or ACA healthcare coverage. You have to wait until the next Special or Open Enrollment period.
Sarah had waited more than 60 days since her workplace coverage ended. She thought she was being smart by saving two months of premiums. Instead, she had forfeited her right to buy an ACA health plan.
Do not play chicken with this deadline. The calendar always wins.
This is the most common mistake we see with new Texans.
People move to Texas every single day. They come from California or New York or Oklahoma. They get settled in their new apartment in Dallas or Houston.
They call us and say, "I moved! That’s a qualifying event. I want to buy insurance."
Kevin always asks the same question. "Did you have health insurance for at least one day in the 60 days before you moved?"
If the answer is silence and you didn't have a job loss, you may be out of luck.
Many people are moving to a new area specifically because they are starting over. They might not have had coverage in their old state. They assume moving gives them a fresh start.
It does not.
To use the "Permanent Move" qualifying event, you must prove you were insured before you packed the U-Haul.
The government created this rule to stop people from moving to a new state just to get medical care. If you were uninsured in Ohio, you stay uninsured in Texas.
Let’s say you have your Golden Ticket. You are within the 60-day window. You pick a plan.
You are not done yet.
The Health Insurance Marketplace does not operate on the honor system. They do not trust you.
They will ask for proof.
If you say you lost coverage, they want a letter from your employer or insurance carrier. It must show your name. It must show the exact date the coverage ended.
If you say you got married, they want to see the marriage license.
If you say you had a baby, they want the birth certificate.
There are documents needed to prove these happened. If you don't upload them, they will happily cancel your policy.
Kevin spends his day helping clients secure coverage. We know exactly what the government wants to see. We don’t want to get you kicked off your plan three months later due to a lack of documents needed.
We have established that you cannot wait until you are sick to buy insurance. But even when you follow the rules, the coverage is not instant.
This is another shock for people used to Amazon Prime.
If you enroll in a plan today, it generally does not start tomorrow.
In most cases, if you enroll between the 1st and the 15th of the month, coverage starts the first of the next month.
If you enroll after the 15th, you might have to wait until the first of the following month.
There are exceptions. The government is nice to babies. If you have a newborn, coverage can backdate to the day of birth.
You need to plan for that potential gap. If you wait until the last minute, you might be exposed for a few weeks without the protection of essential health benefits.
So what happened to Sarah?
She missed her 60-day window. She could not get an Affordable Care Act plan. She was blocked from coverage for pre-existing conditions.
But Kevin didn't leave her hanging.
At Insurance For Texans, we have access to private coverage options outside of the government marketplace.
By looking at various options, Kevin was able to build a temporary safety net for Sarah. It wasn't the perfect plan she wanted originally. But it kept her from being completely exposed to financial ruin and also included virtual 24/7 care services.
She was able to use that health plan, and then look at coverage changes during Open Enrollment. Kevin helped her move to a full comprehensive plan then.
The rules for Special Enrollment Periods are confusing. The government websites are frustrating. The deadlines are unforgiving.
One wrong click can get your application denied. One missed document can get your policy cancelled.
You do not have to guess.
Our deeply experienced advisors deal with this every single day. We know which events count. We know which documents you need. We know how to get the system to accept your application.
If you are like Sarah and you missed your window, do not wait until you are in the ambulance. Do not wait until day 61.
Click the Button Below to Check Your Eligibility for Special Enrollment