I’m reaching out here for any advice you may have from personal experience or knowledge of how the Marketplace works.
This past Friday, I unexpectedly lost my state health insurance. I immediately signed up for an insurance plan through the Marketplace, but the start date is listed as 11/1/24.
I have a prescription I need to fill ASAP next week for urgent mental health needs. This Rx costs $500 out of pocket, with a manufacturer coupon provided. There are no generics available.
I called the Marketplace, and my concern was “escalated to a case worker”—but I was told the review period could take up to 30 days. In other words, through no fault of my own, I am left uninsured even while I immediately signed up during my SEP.
I cannot believe our country works like this. I also signed up for a plan on the insurance website independently (haven’t paid the premiums yet), in order to explore if I have better recourse rectifying the problem through them. That route is TBD, as I need to call back Monday morning (the department was closed by the time I reached this point in the saga).
I’ve also been told about free community health centers, and left voicemails for a bunch of them near me. One called me back today articulating concern, as these centers tend to be booked up for weeks and an initial appointment with a doctor is needed for Rx refills.
I will continue pursuing any and all routes available, but wanted to ask:
Does anyone have any advice or ideas on how to obtain a resolution here? Is there any way I can escalate my case any further through the Marketplace? Are there SOS Rx programs (eligible in MI) out there?
I sincerely appreciate any help you may be able to provide. Thank you!
I’m confused about the part of losing your state health insurance. What was the reason? Did your income increase, did you age out, or did you move to another state? They usually send a letter in advance to inform you that your benefits are ending. I’m sorry if you didn’t receive that letter—it should also be available in your benefits portal.
Thank you for this—I totally hear your comment and didn’t include the explanation because it is pretty long and wild…but I will elaborate here as soon as I can!
You certainly don’t owe anyone an explanation, just figured that if it was an erroneous reason for loss of coverage and you’re still eligible and have always been eligible for Medicaid (or whatever state assistance you had before), then that’s an avenue to persue.
As far as I know, during a special enrollment period, coverage usually starts on the first of the next month if you pay by the 15th, including if you qualify for a special enrollment period. If it’s a regular enrollment period, you might get stuck for an extra month since they’ll deny the special enrollment (in November), and you’ll only be eligible for coverage starting January 1. That happened to me. Do you have the option to use COBRA from your current insurance?
Yes, this happened to me too. Lost coverage at the end of November, so they wouldn’t let me start coverage until Jan 1st and went a month without coverage
Wow, thank you for sharing that—it’s really helpful, though sounds frustrating AF in your case too.
My former plan, part of my state’s Medicaid expansion, is closed, with no ability to carry on benefits in the interim. I had short-window opportunity to file an appeal for a hearing before an administrative judge—and would have been covered under Medicaid until the result of that hearing—but my case worker assured me in writing that she would reinstate my benefits before they would be canceled. I was ready to submit the appeal, too. Feels particularly entrapping…
I didn’t have any problems without coverage in December, thankfully, as I didn’t have an emergency. I was eligible for retroactive COBRA through the end of November and planned to sign up for marketplace coverage in December and pay for COBRA for the previous two months if needed. However, in November, they denied my special enrollment because they were in open enrollment. It doesn’t make sense since you can’t get coverage for December that way. If you want marketplace coverage, I recommend choosing a plan by October 15 so that it’s effective on November 1, while you continue to see if they’ll make an exception. They told me over the phone before that they can do that, but I’m not sure if that information is accurate.
Check with your pharmacy to see if they know of any programs. They may have information, or they might not. Additionally, look at GoodRx; they might offer a coupon.
Check with your pharmacy to see if they know of any programs. They may have information, or they might not. Additionally, look at GoodRx; they might offer a coupon.
Depending on where you live, you might have success using the methylphenidate coupon on GoodRx.com to help you until your insurance starts. In my area, it’s about $10 for a 30-day supply.