Even with 1.2 million people enrolled by Monday's deadline, California's health exchange isn't done adding to the Obamacare rolls — and it won't be for quite some time.
In the months to come, it's estimated that several hundred thousand more Californians could qualify for a special enrollment period as college students graduate, families move and workers change jobs.
But health insurers say the state's current rules for late sign-ups rely too much on the honor system and invite abuse by people waiting until they get sick.
Consumer advocates disagree, and they don't want the Covered California exchange to impede people from getting coverage when their circumstances change.
State officials are still determining the procedure for special enrollment, which officially began Tuesday.
"We don't want anyone to think special enrollment is a free pass if they didn't sign up in time," said Peter Lee, executive director of Covered California. "We're looking at what is the right way to document it, to make sure you can't commit fraud."
The Affordable Care Act set a limited, six-month window for enrollment in the first year to help ensure that enough healthy customers join the insurance pool so their premiums can help pay for the costly care needed by older and less healthy participants. There are also tax penalties for being uninsured.
Many older, sicker consumers were among the first to enroll during the fall because the federal law guarantees coverage for all applicants regardless of preexisting conditions.
Before it gets to special enrollment, Covered California must still take applications from thousands of people who couldn't sign up before midnight Monday because the state's website kept crashing or running painfully slow. In response, the exchange gave those applicants until April 15 to finish enrolling.
What happens after that, however, is still subject to some debate.
The health law describes numerous "qualifying life events" that open the door to special enrollment, which runs until open enrollment starts again Nov. 15. Enrollment in Medi-Cal, the state's Medicaid program for the poor, runs all year.
Those life events include marriage, divorce, having a baby or adopting a child, moving to a new area or losing a job and the health coverage that came with it.
Last month, the Covered California board approved emergency rules for 90 days that require consumers to simply attest that they have experienced one of those qualifying events. The current rules don't ask people to provide any proof or documentation.
Health insurers in California are pressing the exchange to impose stricter rules.
"People would take advantage of Covered California," said Charles Bacchi, executive vice president at the California Assn. of Health Plans. "We feel more comfortable with industry standard practice, which has been to ask people for some documentation or proof of a qualifying event."
But some consumer advocates say worries about fraud are exaggerated and that requiring people to sign under the penalty of perjury is sufficient.
"Any time you put paperwork barriers in people's way it makes the whole system more expensive and cumbersome. Consumers tell the truth most of the time," said Elizabeth Landsberg, legislative director at the Western Center on Law and Poverty in Sacramento. "It could be several hundred thousand people who qualify for special enrollment" in California.
Nationally, health-policy experts estimate that about 4 million Americans may qualify for special enrollment.
If additional requirements are added, Landsberg said, it's important for consumers to still get access to coverage immediately and then have 90 days to produce documentation. She said she wouldn't want people left waiting for paperwork showing they lost previous coverage at work or a utility bill confirming a move.
During open enrollment, many consumers complained to Covered California about delays in processing their application and verifying income, citizenship and other data. For their part, many health plans have struggled to keep pace with high enrollment and get bills and identification cards out on time.
As new enrollees join during special enrollment, other exchange customers will leave for a variety of reasons, such as getting coverage through work. Close to half of Covered California customers eligible for premium subsidies could leave within a year, according to a report published Wednesday by the UC Berkeley Center for Labor Research and Education.
Some health-law supporters are planning a big marketing campaign to promote special enrollment in the weeks ahead as graduation and wedding season kicks in.
Young Invincibles, a national organization promoting the health law, said it will be reminding people through social media and mobile apps about the opportunity to sign up this summer.
Among consumers ages 18 to 34, "there will be a lot of people touched by a wedding, graduation or having a baby," said Tamika Butler, California director for Young Invincibles. "We want to make sure young people know there was a deadline, but you will have these other chances."
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