QUESTION

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

Individuals with coverage | Individual and Marketplace Health Coverage
ANSWER

If you want coverage that meets minimum ACA standards, you have to sign up during the annual open enrollment period, unless you have a qualifying life event that entitles you to a special enrollment opportunity. However, during plan year 2022, individuals with household income under 150 percent of the federal poverty level and American Indians and Alaska Natives may enroll year-round.

Most special enrollment periods provide you with 60 days from the date of the qualifying event to enroll in a plan. If you did not have a timely notice of a triggering event, then you have 60 days from the day you became aware of a triggering event. 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 loss of coverage due to divorce or legal separation. 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; note that 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).
  • Death of someone enrolled in your marketplace plan
  • 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 (check with the marketplace in your state to see if this opportunity is available).
  • Losing eligibility or being determined ineligible 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).
  • Losing eligibility for premium-free Medicare Part A. Note that you don't qualify for a special enrollment period if you didn't pay your Medicare premium or you lose Medicare Parts B, C, or D only.
  • Income changes sufficient to affect eligibility for premium tax credits. A special enrollment period is available if you experienced a change in income or household size that makes you newly eligible for premium tax credits or cost sharing reductions and had minimum essential coverage for at least one day during the 60 days prior to your income change. Alternatively, you are eligible for a special enrollment period to switch plans if you experienced an income or household size change that makes you newly ineligible for premium tax credits or cost sharing reductions as long as you are currently enrolled in Marketplace coverage.
  • 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.
  • Leaving incarceration.
  • 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).
  • Following technical or operational issues with the marketplace including resolving a data-matching issue with the Marketplace that extends beyond the open enrollment period or facing enrollment errors and misrepresentation in application due to inaction, mistake or misconduct from the marketplace or an enrollment assister.
  • 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. 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. 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;
  • In 2022, individuals with household income under 150 percent of the federal poverty level may enroll once per month;
  • Additionally, 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 period 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 if there is a different deadline.

(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; CMS, Emergency and Major Disaster Declarations by the Federal Emergency Management Agency (FEMA) – Special Enrollment Periods (SEPs), Termination of Coverage, and Payment Deadline Flexibilities, Effective August 9, 2018, August 9, 2018; 84 FR 17454, April 25, 2019; 84 FR 41292, August 14, 2019)

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