Signing up for a health insurance policy isn't something you can do whenever you want. When the Affordable Care Act (ACA) went into effect, the time between November and January was dedicated as the only time Americans can sign up for health insurance such as marketplace coverage.
This time period is known as “open enrollment,” and it keeps people from signing up for an insurance plan as soon as they get sick or injured.
But what if you need to sign up for health insurance outside of open enrollment, like when you lose employer-sponsored coverage, age out of a parent's plan, or move to a new state? Cases like these are when “special enrollment periods” come in handy.
In this article, we'll explain what a special enrollment period is, what life events qualify you for one, and what to do once you do qualify.
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What is a special enrollment period?
A special enrollment period is a time when you're allowed to make changes to your health insurance plan even though it's not an open enrollment period as defined by the ACA.
Certain qualifying events and exceptional circumstances will trigger a special enrollment period, allowing you to change your health coverage for a certain period after the triggering event (more on those in the next section).
Generally speaking, you'll have 60 days following the event to enroll in a new health plan through the federal or state-based marketplaces. Keep in mind that you're eligible to enroll in Medicaid or the Children's Health Insurance Program (CHIP) at any time.
If you don't make the necessary changes to your health insurance during the special enrollment period, you'll have to wait until the next open enrollment period to make any changes.
How do I know if I qualify for a special enrollment period?
To qualify for a special enrollment period, you need to have a qualifying life event occur that would cause needed changes to be made to your health coverage.
There are four basic types of qualifying events:
- Loss of health coverage
- Losing job-based health coverage
- Your individual health insurance plan or marketplace coverage no longer exists
- Losing student health plan coverage
- Losing eligibility for Medicaid or CHIP,
- Losing coverage through a family member, such as turning 26 if you're on a parent's plan
- Offer of new health benefit
- Ex: Being offered a health reimbursement arrangement (HRA) such as a qualified small employer HRA (QSEHRA) or individual coverage HRA (ICHRA), or other employer-sponsored health coverage
- Changes in household
- Got married
- Had a baby, adopted a child
- Placed a child in foster care
- Got divorced or went through legal separation and lost your current coverage
- Someone in your family died, and you lost health insurance coverage
- Changes in residence
- Moving to a new zip code
- Moving to the U.S. from a foreign country or a U.S. territory
- Moving to or from the place you both live and work (if you're a seasonal worker)
- Moving to or from where you attend school
- Moving for medical treatment options doesn't qualify you for a special enrollment period
Other ways to trigger a special enrollment period
A qualifying life event isn't the only way to qualify for a special enrollment period. Other circumstances that can allow you to make changes to your health coverage include experiencing an enrollment or policy information display error, gaining or becoming a dependent due to child support, or getting an appeal decision that's in your favor.
You'll also qualify if you gain membership in a federally recognized tribe, become an Alaska Native Claims Settlement Act (ANCSA) Corporation shareholder, or begin or end service with AmeriCorps State, AmeriCorps National, VISTA, or NCCC.
You may also qualify for a special enrollment period if you previously qualified in the previous 60 days but missed your deadline to enroll in health plan coverage due to the COVID-19 Public Health Emergency.
In September 2021, the U.S. Department of Health & Human Services (HHS) established a new special enrollment period for households with income of less than 150% of the federal poverty level (FPL), as long as the applicant is also eligible for premium tax credits that cover the cost of a benchmark plan. In 2022, 150% of the FPL corresponds to $19,320 for a single person.
What do I do if I qualify for a special enrollment period?
If you've experienced one of the qualifying events listed above, you're ready to apply for a special enrollment period. You can do this either through Healthcare.gov1 or your state exchange2.
Your application will be different depending on whether you've experienced a qualifying life event or if you've had another special circumstance that will affect your health coverage.
If you've experienced a qualifying life event, you can apply online. You can check to see if your life event qualifies by going to Healthcare.gov and answering a few screening questions3 to see if you qualify for a special enrollment period.
If you have a special circumstance rather than a qualifying life event, you'll want to contact the marketplace call center directly at 1-800-318-2596. A representative will ask a few questions about your situation to help decide if you're eligible for a special enrollment period.
What do I do if I believe I qualify but I was turned down?
If you believe that you should qualify for a special enrollment period, but your request was denied, you can submit an appeal. You have 90 days to ask for an appeal.
Conclusion
While the annual open enrollment period is the ideal time to sign up for health insurance, life is messy, and things can happen unexpectedly. That's why special enrollment periods were created to help you make the necessary changes to your health insurance when the unexpected happens.
This blog article was originally published on August 1, 2019. It was last updated on September 29, 2022.
