When it comes to health insurance, you typically have one small window of time to sign up. The open enrollment period runs from November through January in most states. It's the designated time of year for Americans to make changes to their current policies or enroll in individual marketplace coverage.
Having this set time frame is meant to keep people from signing up for an insurance plan only after they get sick or injured. But don't worry; there are some exceptions for when life throws an unexpected curveball your way.
For example, you can participate in a special enrollment period (SEP) if you lose coverage, move to a new state, age out of a parent’s plan, or have a baby. Several other situations can qualify you for a SEP as well.
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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When is open enrollment?
It’s important to know what the open enrollment calendar looks like so you’re not caught off guard when it comes to your coverage. By being aware of these important dates, you’ll know when you’re able to freely enroll in or change your health insurance policy. If open enrollment ends before you can make your adjustments, that’s when you’ll need to qualify for a special enrollment period.
Here’s a breakdown of the important dates during the open enrollment period:
- November 1: This is when open enrollment starts for health coverage for the next plan year in most states. This is when you can enroll in, re-enroll in, or change your health plan selection through the federal Health Insurance Marketplace.
- December 15: This is the last day you can enroll in or change plans for your coverage to start on January 1.
- January 15: This is when open enrollment officially ends for most states.
- February 1: Coverage starts for those who enroll in or change plans from December 16 through January 15 and pay their first premium.
How does a special enrollment period work?
It takes a major life change to qualify for a special enrollment period. This is when you can make changes to your health insurance plan even though it's not an open enrollment period as defined by the Affordable Care Act (ACA). Keep in mind, if you qualify for Medicaid or the Children's Health Insurance Program (CHIP), you're eligible to enroll at any point in the year.
Certain qualifying events and exceptional circumstances will activate a special enrollment period, allowing you to change your health coverage for a certain period following the triggering event. Generally speaking, you'll have a 60-day special enrollment period after the event to enroll in a new health plan through federal or state-based marketplaces.
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 for the following health plan coverage year.
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 necessary changes to be made to your health coverage.
There are four basic types of qualifying events:
- Loss of health coverage
- Offer of new health benefit
- Changes in household
- Changes in residence
Loss of coverage
This includes losing employer-sponsored coverage, student health plan coverage, and eligibility for Medicaid or CHIP. Aging out of your parent’s plan is also a loss in coverage. You’ll lose your dependent status when you turn 26 and are on a parent’s plan.If your current plan or marketplace coverage no longer exists, you also fall under this qualifying life event.
Offer of a new health benefit
If you’re offered a new health benefit, like a health reimbursement arrangement (HRA) such as a qualified small employer HRA (QSEHRA) or individual coverage HRA (ICHRA), or other employer-sponsored plans, it’s considered a qualifying event.
Changes in household
Several scenarios are accepted under this qualifying event. If you get married, have a baby, adopt a child, or place a child in foster care, you may qualify for a SEP. This also applies to people who got divorced or went through legal separation and lost their current coverage. If someone in your family died and you lost health insurance coverage as a result, that would also be considered a change in the household. Remember, situations involving a domestic partnership vary from state to state.
Changes in residence
Most forms of relocation are seen as a qualifying life event. If you’re moving to a new zip code or to the U.S. from another country or a U.S. territory, you can change your health coverage. This also covers students who move to or from where they attend school. Seasonal workers also fall under this category if they move to or from the place where they live and work. Keep in mind that moving for medical treatment options doesn't qualify you for a special enrollment period.
Additional qualifying changes for a special enrollment period
Other circumstances that allow you to change 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. Survivors of domestic abuse are also eligible for a special enrollment period to enroll in a health plan that's separate from their abuser. Those who leave incarceration may also become eligible for a special enrollment period.
Additionally, you'll 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 could 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 a natural disaster1 or a national or state-level emergency.
Special enrollment for families with a low household income
There are also enrollment exceptions for people living at the federal poverty level. In September 2021, the U.S. Department of Health & Human Services (HHS) established a new special enrollment period for households with an annual 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. The special enrollment period was specifically created to make it easier for low-income Americans to enroll in ACA-compliant plan coverage throughout the year instead of just during open enrollment or when they experience a qualifying life event.
According to HealthInsurance.org2, if you’re a single person who’s enrolling for coverage in 2023, an income of no more than $20,385 amounts to 150% of the poverty level. It’s $48,705 for a household of five people.
If you’re not sure if you’re eligible, there are several online tools available to help you calculate whether or not you qualify for premium tax credits, and in turn, qualify for the low-income special enrollment period. The Kaiser Family Foundation’s Health Insurance Marketplace Calculator3 is one option.
I qualify for a special enrollment period; now what?
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.gov4 or your state exchange5.
Your application will differ depending on whether you've experienced a qualifying life event or 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 questions6 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 coverage 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. Even if you miss the 90-day timeframe, don't lose hope. There's a chance you could get an extension. When filing your appeal, you should explain why you missed the deadline.
Conclusion
While the annual open enrollment period is the ideal time to sign up for employer-sponsored and individual coverage health insurance, you have options for when life gets complicated. If you're experiencing an unexpected life event, a special enrollment period exists to make sure your health insurance coverage remains intact.
This blog article was originally published on August 1, 2019. It was last updated on March 7, 2023.
- https://www.healthcare.gov/sep-list/
- https://www.healthinsurance.org/special-enrollment-guide/an-sep-if-your-income-doesnt-exceed-150-of-the-federal-poverty-level/
- https://www.kff.org/interactive/subsidy-calculator/
- http://healthcare.gov/
- https://www.healthcare.gov/marketplace-in-your-state/
- https://www.healthcare.gov/screener/#/
