It is a well-known fact that enrollment in the individual health plan is possible only during the open enrollment period. The open enrollment period generally runs from November 1 through December 15 in most of the states, though some state-run exchanges have different deadlines. However, outside the open enrollment period, new enrollment or changes in plans is usually not possible and is only allowed for individuals having a qualifying event. The open enrollment window is applicable for both on and off the exchange plans, and qualifying events is essential for enrolling outside the open enrollment.
Why Enrollment Window is Limited?
The individual health insurance marketplace has a limited enrollment window because now health coverage is a guaranteed issue for all applicants, irrespective of whether they have pre-existing conditions or not. The open enrollment window allows people to buy coverage without waiting to be sick. However, sometimes people have a life event that requires them to enroll in a new health plan outside the open enrollment period. That is the time when special enrollment periods come in. The special enrollment period has been in use for a long time in the employer-sponsored health insurance market, now it is a part of the individual market too. Some qualifying events are specific to the individual market under the Affordable Care Act.
What are Qualifying Events?
A list of qualifying events triggers a special enrollment period during which people are allowed to enroll in a plan or switch to a different plan outside the open enrollment period. In most of the cases, a special enrollment period in the individual market is only available if the applicants had health coverage before the qualifying event. However, some exceptions are there like a special enrollment period triggered by the birth or adoption of a child or if a person moves out of the Medicaid coverage gap. Special enrollment period in the individual market should only be considered as a way to change coverage, as people cannot use this period to go from being uninsured to insured. Some of the qualifying events that trigger special enrollment period are:
Marriage – Individuals who are getting married have a 60-day special enrollment period that begins from the day of their wedding. The coverage will be effective from the first of the month following their enrollment, regardless of the date they enroll. This rule has been implemented so that at least one spouse has coverage before the wedding.
Loss of other coverage – The plan individual is losing has to be a plan with minimum essential coverage, as with a short-term plan or accident supplement plan people will not qualify for a special enrollment period. Besides, loss of coverage should not be due to non-payment of premiums, rescission, or self-cancellation of plans. Loss of coverage event will qualify in a scenario like an insurer exiting the market, or loss of access to an employer-sponsored plan due to quitting of job or due to divorce. Individuals have 60 days before and 60 days after the loss of coverage during which they can enroll in a new health plan.
Gaining Dependent or becoming dependent – This qualifying event can occur as a result of birth or adoption of a child, or placement in foster care. The special enrollment period starts for individuals having a baby that starts the day the baby is born, and the coverage is backdated to the baby’s birth or adoption date. HHS has developed a similar special enrollment period for people whose family size changes due to other reasons like divorce or the death of a dependent.
Moving permanently to a new area where different plans are available – To consider this as a qualifying event, the move should be permanent, and some of the plans available in the new area must be different from the plans that were available in their prior location. A permanent move will trigger a special enrollment period if people had minimum essential coverage for at least 60 days before moving to the new location. However, people should keep in mind that they cannot go uninsured and then get coverage by moving to a new area when in need of healthcare. HHS has also clarified that moving to a new location for treatment does not qualify as a permanent move.
The renewal date of the individual plan falls outside the open enrollment – New plans under the Affordable Care Act run on a calendar year and usually renew on January. However, grandmothered and grandfathered plans may have renewal dates at any time of the year. Therefore, individuals having plans that have renewal outside of the open enrollment period, then they are allowed to switch to an ACA-compliant plan instead of renewing their existing plan.
Becoming a citizen of the country – Individuals on becoming citizens of the U.S. qualify for a special enrollment period, though it applies only within the exchanges. Off-exchanges health plans cannot enroll people due to this qualifying event.
An error in the enrollment process – If an error has occurred in the enrollment process due to the fault of the exchange, or by an enrollment assister, or by the health insurance carrier. In such circumstances, the exchange or carrier can re-enroll the applicant outside of open enrollment to resolve the problem.
If an employer-sponsored plan becomes unaffordable or does not provide minimum value – As per 2020, employer-sponsored plans are considered affordable, if employee’s portion of the premium is not more than 9.78% of the household income. However, if the employer’s plan becomes unaffordable mid-year, which may be either due to an increase in employee’s premium or because of the employee’s income drops, then the employee becomes eligible for a special enrollment period. The special enrollment period also applies if the employer-sponsored plan reduces benefits such that it does not cover a minimum of 60% of the average enrollee’s costs.
People experiencing any of these qualifying events and meeting the eligibility criteria have a special enrollment period that usually lasts for 60 days. Though, in some cases, the special enrollment period begins 60 days before the qualifying event and continues for 60 days after the qualifying event.