The Affordable Care Act (ACA or Obamacare) created open enrollment periods, which are periods each year during which people can buy health insurance in the private market (non-group health insurance). People with job-based plans follow their company’s enrollment periods, those on Medicare or other types of government programs follow individual guidelines, and people on Medicaid or CHIP can enroll year-round. For anyone buying health insurance privately – that is, through a broker, directly from an insurer, through the federal or state marketplaces, or via an independent website – there’s an annual enrollment period to sign up.
This ensures that people get coverage before they get sick and prevents people from signing up after they’re diagnosed with a medical problem. It’s the same logic used in other kinds of insurance. In other words, you can’t buy tornado insurance after your home gets destroyed by a tornado. This philosophy keeps costs down and ensures that companies can pay claims based on the premiums already collected from the risk pool at large. The most recent signup period ran from November 1, 2017 through December 15, 2017 in all but a handful of states. For states that expanded enrollment, the signup period ended on January 31, 2018.
What is a QLE?
Because life can be complex, the ACA also allows people to sign up outside of the open enrollment period if they experience a “qualifying life event” (QLE). The guidelines for qualifying life events haven’t always been identified in detail or stringently upheld. Plenty of people took advantage of QLEs and lax loopholes to sign up outside of open enrollment, which created some problems for the insurance market as a whole. In April 2017, the Centers for Medicare and Medicaid Services issued new rules regarding qualifying life events, essentially tightening the loopholes and clarifying what counts as a QLE. Life events that qualify you to sign up for health insurance outside of open enrollment can be lumped into four categories:
- Household and family events
- Loss of qualifying health insurance
- A change in your location
- Other, typically less common situations
Family changes
Household and family events center on changes that happen to your family. This could include getting married or divorced, having or adopting a child, and the death of a family member.
Insurance changes
If you lose your existing health insurance, then you may also qualify for a special enrollment period (SEP). Changes in insurance might mean turning 26 and being ineligible to stay on your family’s medical plan, losing your current job-based coverage, or becoming ineligible for Medicaid, Medicare or CHIP when you were already enrolled in one of these programs.
Residence changes
Significant residence changes count as a qualify life event. If you move from one zip code to another, start school and move to a new city, leave school, start a new job in a new place, or move from transitional housing into a permanent place, then you may be able to sign up for coverage outside of open enrollment.
Other changes
Other life events that qualify you to sign up for health insurance during special enrollment periods include leaving incarceration, becoming a U.S. citizen, gaining membership in a federally recognized Native American or Alaska Native tribe, or experiencing a change in income that affects your coverage eligibility. There are several situations that fall into the “other” category.
Note that losing your health insurance due to nonpayment – i.e., you didn’t pay your premiums – or because you misrepresented information on your application and were then dropped from your plan does not qualify as a QLE that would open a special enrollment period in your case. The QLE based on losing your current health insurance must be because the loss was involuntary.
Exceptional SEPs
We mentioned above that there are “other” life changes that can open up special enrollment periods, situations like leaving incarceration or becoming a U.S. citizen. But there are even more complicated and atypical situations that might allow you to buy health insurance outside of open enrollment. These include:
- Domestic violence or spousal abandonment
- Child custody scenarios, either becoming a dependent or gaining a new one
- Natural disasters, such as the recent hurricanes or California wildfires
- Unexpected hospitalization, temporary cognitive impairment or other incapacitation
- Technical errors or errors of information when signing up on the marketplace
This last point about errors during the signup period can be a gray area – as can many of these qualifying life events – but it’s designed for people who get incorrect information when they’re enrolling in a health plan or those who meet technical trouble when enrolling that prevents them from picking the right plan. As with many QLEs, exceptional circumstance events can be tough to prove. But if you’re denied a special enrollment period, you have the right to appeal the decision by mailing in a state-based appeal form.
Special Signup Period for 60 Days
The HealthCare.gov website offers a full list of qualifying life events that may allow you to buy health insurance outside of open enrollment. But keep in mind that the guidelines are stricter than they were before, and you will have to submit supporting documentation to prove that you experienced a QLE to enroll during a special enrollment period.
For most situations, you have 60 days from the date of the event to sign up for a health plan. If you get married on June 1, for instance, you would have until July 30 to buy health insurance. Some circumstances set additional conditions. For example, if you move and want to take advantage of the SEP for changing residence, you must prove that you had qualifying health insurance for at least one day during the 60 days before you moved. If you know that you’re going to lose your job-based insurance within the next 60 days (but haven’t yet), you may also be able to buy coverage during a special enrollment period.
The sooner you apply for a special enrollment period, the better. Check the guidelines on HealthCare.gov carefully, and be prepared to send in the right documents to support your claim for an SEP. Once you pick a health plan, you have 30 days from the date you sign up to send in your documents, so don’t wait. Your coverage is usually effective on the first of the month after you enroll, but you can’t actually use your plan until you’ve paid the premium and your SEP has been confirmed by the marketplace. The marketplace screening tool will tell you which documents to send in and what you need to do to prove your QLE.
Keeping up with special enrollment periods, qualifying life events and other important details can be tough, especially when you’re going through the kinds of events that qualify you for an SEP in the first place. If you need help, talk to an independent agent about your options for coverage outside of open enrollment. Even if you don’t qualify for a special signup period, you may have other, non-ACA options for buying health insurance throughout the year.
