QUESTION

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

Individuals with no coverage | Open and Special Enrollment Periods
ANSWER

In general, you can only buy or change your private, non-group health plan coverage outside of the open enrollment period if you have a 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 the federally facilitated marketplace, although New York’s state-based marketplace categorizes this as a qualifying event.
  • Gaining a dependent through adoption, foster care or a court order.
  • 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. 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.
  • For people enrolled in a marketplace plan, income increases or decreases sufficient to change eligibility for premium tax credits and/or cost-sharing reductions.
  • For the marketplace, 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.

Note that some triggering events will only qualify you for a special enrollment opportunity in the 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 Native American or Alaskan Native, he or she can enroll into a marketplace plan or change his or her marketplace plan once per month.

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. (45 C.F.R. § 155.420(d); 82 Fed. Reg. 18346, April 18, 2017; CMS, Overview: Special Enrollment Period Pre-enrollment Verification (SEPV), June 2017).

Individuals with no coverage
Individuals with coverage
Coverage for small employers
Post enrollment issues