Enrolling in Individual Health Insurance With a Qualifying Event

Qualifying events trigger special enrollment periods

Open enrollment in the individual health insurance market runs from November 1 through December 15 in nearly every state (several of the state-run exchanges have different deadlines).

Outside of open enrollment, plan changes and new enrollments can only be completed if you have a qualifying event, although Native Americans can enroll year-round in a plan through the exchange (Medicaid and CHIP enrollment are also year-round).

The open enrollment window applies both on and off the exchange, and qualifying events are necessary if you're enrolling outside of open enrollment, regardless of whether you're buying your plan through the exchange or directly from a health insurance carrier. [Premium subsidies are only available if you enroll through the exchange; if in doubt, an exchange plan is your best bet, as it provides you with the opportunity to retroactively claim the premium subsidies if your income ends up being lower than you thought it would be.]

Father holding baby
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Why Is Enrollment Limited?

The individual market has to have a limited enrollment window because coverage is now guaranteed-issue for all applicants, regardless of whether they have pre-existing conditions. The annual open enrollment window prevents people from waiting until they're sick to buy coverage. But sometimes, people have a life event—other than getting sick!—that requires the ability to enroll in a new health plan outside of open enrollment. 

That's where special enrollment periods come in. They've long been used in the employer-sponsored health insurance market, and now they're part of the individual (self-purchased) market too. And while there's a lot of overlap in terms of what triggers a special enrollment period, there are some qualifying events that are unique to the individual market under the Affordable Care Act.

[This article is specific to qualifying events in the individual market; qualifying events that pertain to employer-sponsored plans are described here, and the differences between special enrollment periods in the individual and employer markets are discussed in this article.]

What Counts as a Qualifying Event?

There's a substantial list of qualifying events that will allow you to enroll in a plan or switch to a different plan outside of open enrollment. In general, they're common-sense rules, and they wouldn't apply to people who simply changed their mind about needing health insurance part way through the year.

It's important to note that HHS has stepped up the verification process for qualifying events in recent years—if you're enrolling using a qualifying event, be prepared to provide proof of eligibility.

And in most circumstances, a special enrollment period in the individual market is only available if the applicant already had coverage prior to the qualifying event. There are some exceptions to this, such as the special enrollment period triggered by the birth or adoption of a child, and the special enrollment period for a person who moves out of the Medicaid coverage gap. But in general, special enrollment periods for individual market coverage should be thought of as a way to change coverage, rather than go from being uninsured to insured.

But if you experience any of these qualifying events and meet the eligibility criteria, you'll have a special enrollment period, which generally lasts for 60 days (in some cases, the special enrollment period begins 60 days before the qualifying event and continues for another 60 days after the qualifying event). In most cases, coverage will be effective the first of the following month as long as you enroll by the 15th of the month, although there are some exceptions and some states have later deadlines:

  • Loss of other coverage. The plan you're losing has to be considered minimum essential coverage (ie, it can't be something like a short-term plan or an accident supplement). And the loss of coverage can't be a result of non-payment of premiums, rescission, or self-cancellation. So this applies in scenarios such as your health plan exiting the market, or loss of access to an employer-sponsored plan due to divorce, leaving a job, etc. (even if you're offered COBRA, you still qualify for a special enrollment period during which you can purchase an individual plan instead). You've got 60 days before and 60 days after the loss of coverage during which you can enroll in a new plan. 
  • Becoming a dependent or gaining a dependent as a result of birth, adoption, or placement in foster care. If you have a baby, your special enrollment period starts the day the baby is born, and coverage can be backdated to the baby's birth/adoption date. HHS has made a similar special enrollment period applicable to people whose family structure changes for other reasons, including divorce or death of a dependent. Note that while the birth of a baby is a qualifying event, pregnancy is not (except in New York and Connecticut, where state laws provide a special enrollment period when a woman finds out she's pregnant).
  • Marriage. If you get married, your 60-day special enrollment period begins the day of your wedding, and coverage will be effective the first of the month following your enrollment, regardless of the date you enroll. This rule has been tightened up to require that at least one spouse already had coverage prior to the wedding, with only a few exceptions.
  • Becoming a US citizen. New US citizens qualify for a special enrollment period, although it's only applicable within the exchanges—off-exchange plans are not required to enroll people due to this qualifying event, although they can choose to do so.
  • A permanent move to an area where different health plans are available. The move can't be temporary, and at least some of the health plans available in the new area must be different from the ones that were available in your prior location. HHS has clarified that moving into a hospital for treatment in a new location does not qualify as a permanent move. And a permanent move will only trigger a special enrollment period if you already had minimum essential coverage for at least one of the 60 days prior to the move. In other words, you can't go uninsured and then get coverage by moving to a new area when you're in need of healthcare (there are exceptions for people newly released from incarceration, moving out of the Medicaid coverage gap, or moving back to the US after living abroad).
  • Individual health plan renewal date outside of open enrollment. Under the ACA, new plans run on a calendar year basis, and they all renew on January. But grandmothered and grandfathered plans can have renewal dates at any time of the year. If your plan is up for renewal outside of open enrollment, you're allowed to switch to an ACA-compliant plan instead of renewing your existing plan.
  • An error or problem with the enrollment process that wasn't the enrollee's fault (ie, it was caused by the exchange, or by an enrollment assister or the health insurance carrier). The exchange and/or carrier can re-enroll the applicant outside of open enrollment in order to fix the problem.
  • Your employer-sponsored plan becomes unaffordable or no longer provides minimum value. For 2020, employer-sponsored plans are considered affordable as long as the employee's portion of the premium (for just the employee's coverage - not counting the cost to cover dependents) is not more than 9.78% of household income. If an employer's plan becomes unaffordable mid-year (either because the employee's premium increases, or because the employee's income drops), the employee has access to a special enrollment period. The special enrollment period also applies if the employer-sponsored plan reduces benefits such that it no longer covers at least 60% of the average enrollee's costs (ie, minimum value).
  • You're in the coverage gap in a state that hasn't expanded Medicaid and your income increases to at least 100% of the poverty level. Premium subsidies in the exchange aren't available to anyone with income below the poverty level. In states that haven't expanded Medicaid, people with income below the poverty level who aren't eligible for Medicaid under existing guidelines have no realistic access to health insurance. If their income increases during the year to make them eligible for premium subsidies, they can enroll at that point. 
  • Your income changes and makes you newly-eligible for subsidies. From 2014 through 2019, this special enrollment period has only been available for people who already had a plan in the exchange. [And there is also a special enrollment period for people already enrolled in a plan through the exchange if their income changes and makes them newly ineligible for subsidies.] But prior to 2020, there has been no way for people with off-exchange coverage to switch to an exchange plan—with premium subsidies—if they experienced a mid-year income change that made them eligible for subsidies. But HHS issued new rules in 2019 (that take effect in 2020) that allow a person with off-exchange coverage to switch to a plan in the exchange if their income changes to a subsidy-eligible level (this special enrollment period is optional for state-run exchanges, so it might not be available in every state). Switching to the exchange allows the person to claim their subsidy, but enrollees should also keep in mind that anytime they switch to a new plan mid-year, they'll have to start over with a new deductible and out-of-pocket maximum on the new plan. So in some situations it will make sense to switch to the exchange, while in others it won't. The special enrollment period triggered by a change in income that makes a person newly-eligible or newly-ineligible for premium subsidies is only available if the person was already enrolled in minimum essential coverage (on-exchange or off-exchange) prior to the income change. It's not available if the person was previously uninsured (unless they were in the Medicaid coverage gap, as described above).
  • You already have an exchange plan and the plan "substantially violates" its contract with you. There's an official process for documenting the material violation and requesting a special enrollment period to switch to a different plan. 

If you don't experience a qualifying event, the only time you can enroll in an individual market plan is open enrollment, with coverage effective the following January. This applies to all individual major medical plans, including those sold in the exchange as well as plans sold outside the exchange. [Plans that aren't regulated by the ACA can be purchased year-round, but they generally either involve medical underwriting or aren't suitable to serve as stand-alone coverage—or both.]

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Article Sources
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  2. Cornell Univerity Law School, Legal Information Institute, 45-CFR-155.420, Special Enrollment Periods.

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