This article describes how to apply for Medicaid under the Modified Adjusted Gross Income (MAGI) standard (MAGI Medicaid) and how to apply for a qualified health plan (QHP) through HealthSource RI (HSRI). The article also describes how long that process takes, as well as the Open Enrollment Period (OEP) and Special Enrollment Periods (SEP) during which applicants are allowed to enroll into QHP coverage or change QHPs. (Applicants can enroll into Medicaid at any time of year, and do not need to wait for open or special enrollment periods.)
Everyone seeking health insurance through MAGI Medicaid or through a QHP uses the same application and has the same options for how to apply.
There are four main ways to apply for MAGI Medicaid or QHP health insurance coverage:
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:
Applicants must be prepared to provide the following information about themselves and all members of their household:
In addition, it is often helpful to have the following documents handy:
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).
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 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:
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.
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.
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.
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:
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.
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.
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.
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.
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.)
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.
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
SEPs Allowing Enrollees to Change QHPs
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.
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.)
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.
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:
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.
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.
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.)
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.