If you want coverage that meets minimum ACA standards, you have to sign up during the annual open enrollment period unless you have a household income that is less than 150 percent of the federal poverty level, are American Indian or Alaskan Native, or 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 generally 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 or the cessation of employer or government subsidies for COBRA premiums.
- 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 reductions sufficient to change eligibility for premium tax credits. If you experienced an income reduction that makes you newly eligible for premium tax credits and had minimum essential coverage for at least one day during the 60 days prior to your income change you may qualify for a SEP in all states. If you are currently enrolled in the marketplace and had an income change making you ineligible for APTCs, you may qualify for a SEP that allows you to switch to a new plan at a different metal level.
- 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, or your income is at or below 150 percent of the federal poverty line, the marketplace must provide you with a special enrollment opportunity, but insurers outside of the marketplace do not. This is not an exhaustive list of triggering events, and special enrollment periods may be subject to change, while some may only be available through the marketplace call center or not available in some state-based marketplaces. If you don’t see an opportunity listed above on the enrollment website, or if you’ve experienced a change in circumstances you believe might qualify you for a special enrollment period, contact your marketplace.
Deadline to Apply
When you experience a qualifying event, your special enrollment opportunity will typically last 60 days from the date of that triggering event. Generally, 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. There are a few exceptions to the 60-day timeframe, including:
- Extensions for exceptional circumstances, such as a natural disaster or serious medical condition that prevented enrollment during an open or special enrollment period;
- An emergency SEP for the uninsured in light of the COVID-19 pandemic, still available in certain states;
- If your income does not exceed 150 percent of the federal poverty line and you are eligible for APTCs you have an opportunity to enroll in the marketplace each month;
- If an individual is an American Indian or Alaskan Native, he or she can enroll into a marketplace plan or change his or her marketplace plan once per month.
Other Restrictions and Requirements
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, in certain circumstances, the marketplace may 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. Typically, you will have 30 days to submit the documentation, but check with your marketplace to see what the requirements are during the COVID-19 pandemic. (45 C.F.R. § 155.420(d); CMS, Special Enrollment Periods (SEPs) Information.)