FAQ of the Week: Who Qualifies for a Special Enrollment Period?

Open Enrollment in most states ends Sunday, December 15. After the enrollment period ends, in order to be able to sign up for ACA-compliant health insurance, you will need to qualify for a Special Enrollment Period (SEP). We’ve gathered a few frequently asked questions (FAQs) about Special Enrollment Periods from our Navigator Resource Guide to help you know your options.

Why can’t I buy a plan when I need it? Why do I have to wait for the open enrollment period?

If everyone were allowed to wait until they were sick to buy coverage, premiums would be very expensive. An open enrollment period encourages healthy people to buy a plan to protect themselves from unanticipated events during the year. Health insurers need a mix of healthy and sick people to make premiums fair for everyone.

Can I buy or change private health plan coverage outside of open enrollment?

If you want coverage that meets minimum ACA standards, you have to sign up during the annual open enrollment unless you have qualifying life event that entitles you to a special enrollment opportunity. Some events that trigger a special enrollment opportunity are:

  • Loss of minimum essential coverage or other qualifying coverage. For example, if you lose your employer-sponsored coverage because you quit your job, were laid off, or if your hours were reduced. This also includes “aging off” a parent’s plan when you turn 26 or if you lose student health coverage when you graduate. Note that loss of coverage because you didn’t pay premiums or voluntarily terminate employer-sponsored coverage does not trigger a special enrollment opportunity.
  • Marriage. For marketplace coverage, one spouse must have had other qualifying coverage or minimum essential coverage for at least one day during the 60 days prior to the marriage.
  • Birth; note that pregnancy does NOT trigger a special enrollment opportunity in most states.
  • Gaining a dependent through adoption, foster care or a court order.
  • Loss of dependent status (for example, “aging off” a parent’s plan when you turn 26).
  • Moving to another state or within a state and gaining access to new plans. For the marketplace, you must also have had coverage at least one day in the 60 days prior to moving (this requirement does not apply if you are moving from abroad, or if you are an American Indian or Alaskan Native). You must meet the marketplace residency requirements: 1) you are living at the location and 2) intend to reside at the location or have or are looking for employment.
  • Exhaustion of COBRA coverage; voluntarily dropping COBRA coverage outside of open enrollment will not trigger a special enrollment period.
  • Losing eligibility for Medicaid or the Children’s Health Insurance Program including pregnancy-related coverage through CHIP if coverage was tied to the unborn child. (83 Fed. Reg. 16930, April 17, 2018).
  • Income increases or decreases sufficient to change eligibility for premium tax credits and/or cost-sharing reductions, for people enrolled in a marketplace plan, and for people enrolled in individual market coverage off-marketplace sometime after January 1, 2020 if you enroll through HealthCare.gov. If you are enrolled in off-marketplace individual coverage and your state does not use HealthCare.gov, check with your state’s marketplace to see if you are eligible for this special enrollment period.
  • For people who live in a state that did not expand Medicaid, but would otherwise be eligible, income increases to change eligibility for premium tax credits and/or cost-sharing reductions.
  • Change in immigration status from a non-eligible status to an eligible one.
  • Enrollment or eligibility error made by the marketplace or another government agency or somebody, such as an assister, acting on their behalf.
  • Gaining access to an “individual coverage” Health Reimbursement Arrangement (HRA) through your employer or, if you work for a small business, a Qualified Small Employer Health Reimbursement Arrangement (QSEHRA).
  • Some marketplaces may offer other special enrollment periods, so check with your state’s marketplace for the full list.

Note that some triggering events will only qualify you for a special enrollment opportunity in the health insurance marketplace; they do not apply in the outside market. For example, if you gain citizenship or lawfully present status, the marketplace must provide you with a special enrollment opportunity, but insurers outside of the marketplace do not.

When you experience a qualifying event, your special enrollment opportunity will last 60 days from the date of that triggering event. There are a few exceptions to the 60-day timeframe. If a qualified individual or his dependent loses minimum essential coverage, then the individual has 60 days before or after the last date of coverage to select a plan. This includes loss of employer-based coverage, Medicaid-related pregnancy coverage, and Medicaid-related medically needy coverage. Additionally, if an individual is a American Indians or Alaskan Native, he or she can enroll into a marketplace plan or change his or her marketplace plan once per month.

If you are enrolled in marketplace coverage and have a special enrollment opportunity to switch to a new marketplace plan, in most cases you are restricted to products in the same metal level as your current plan.

When you apply for a SEP, the marketplace will ask you to provide verifying documents prior to enrollment for the following qualifying events: loss of other coverage, moving, gaining or becoming a dependent through adoption or court order, marriage, and a Medicaid/CHIP denial. You will have 30 days to submit the documentation.

My husband and I are retired and spend 6 months of the year in Florida. Can we get a special enrollment opportunity to enroll in a new plan when we move to Florida, even though we’ll only be there for half the year? 

Yes. You have the “intent to reside” in Florida for six months, which the marketplace does not consider a “temporary absence” from your home state. Because you will be there for at least an “entire season or other long period of time,” you may be eligible to enroll in Florida under a permanent move special enrollment period as long as you had coverage for at least one day in the 60 days prior to your move. Make sure to discontinue your previous health plan with the marketplace and the insurer each time you move so you won’t owe two premium payments.

I’m a seasonal worker and spend 4 months of the year in a different state. Can I get a special enrollment opportunity to sign up for a new plan during the time I’m in that state?

Yes, in this situation, you meet the marketplace residency requirements of the state you live in for 8 months and the state you work in for 4 months. Since the residency requirements are met, you are eligible for a special enrollment right to sign up for a new plan when you move to the new state. However, to qualify for a special enrollment period based on moving, you must have had at least one day of coverage in the 60 days prior to your move. If you had marketplace coverage, you can only select a plan that is in the same metal level as your current marketplace plan. Make sure to discontinue your previous health plan with the marketplace and the insurer each time you move so you won’t owe two premium payments.

I have been diagnosed with a serious health condition and will be obtaining care from an out-of-state hospital. During my course of treatment, I’ll be living near the hospital. Can I qualify for a special enrollment period based on this temporary “move”?

No, you do not meet the marketplace residency requirements for the permanent move special enrollment. In your case, you are a temporary resident and you do not intend to live in the state where you’re receiving treatment. Further, the residency requirements for marketplace eligibility are not met in this circumstance. Also, to qualify for a special enrollment based on moving, you must have had health insurance coverage for at least one day in the 60 days prior to your move.

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