Special Enrollment Period for Health Insurance

Qualifying Events That Trigger a Special Enrollment Period

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A special enrollment period is a time when you’re allowed to make changes to your health insurance plan even though it’s not an open enrollment period.

Normally, you’re not allowed to sign up for health insurance or make any health plan changes except during the annual open enrollment period. However, certain qualifying events will trigger a special enrollment period allowing you to make changes for a brief period of time after the triggering event (or in some cases, before the triggering event). If you don’t make the necessary changes to your health insurance during the special enrollment period, you’ll have to wait until the next open enrollment period to make any changes.

Special enrollment periods typically give you 30 days to enroll in a plan offered by your employer (or to add dependents to your employer-sponsored plan). But for plans in the individual market, special enrollment periods generally last for 60 days, and some last for 60 days both before and after a qualifying event.

What Qualifying Events Trigger a Special Enrollment Period?

Things that change the size of your family or cause you to lose other health insurance coverage are likely to trigger a special enrollment period. Examples include:

  • Divorce leaves you uninsured
  • Marriage
  • Birth of a child
  • Adoption of a child
  • Death of a spouse leaves you uninsured
  • Loss of your spouse’s job-based health insurance leaves you uninsured (with or without the option to elect COBRA)
  • Loss of your own job-based health insurance (with or without the option to elect COBRA)
  • Reduction in work hours makes you ineligible for health insurance
  • A Qualified Medical Child Support Order
  • You move outside of your health plan's coverage area, or to an area where different health plans are available.

Qualifying Events Are Similar But Not Identical in Individual Market

Prior to 2014, qualifying events and special enrollment periods applied in the group market (ie, job-based insurance) and for Medicare, but not for the individual market. There was no open enrollment period in the individual market before 2014, because health plans were not guaranteed issue at any time of the year in most states—so there was no need for special enrollment periods; people could apply at any time, and were either accepted or declined by the insurance carriers.

But that changed with the Affordable Care Act. The individual market now has special enrollment periods just like the employer-sponsored insurance market. They are very similar to the qualifying events that trigger special enrollment periods for employer-sponsored insurance and Medicare coverage, but there are some differences. If you're shopping for health insurance in the individual market (on or off-exchange), make sure you understand how qualifying events work for individual plans.

And as noted above, keep in mind that qualifying events give you 60 days to enroll in or make changes to a plan in the individual market, but generally only 30 days to enroll in or make changes to a plan offered by an employer.

How Does a Special Enrollment Period Work?

Here’s an example:

  • Melissa, Ken, and their five children have health insurance through Ken’s job. Melissa also works. Her job offers health insurance to employees and dependents, but not to spouses. During the last open enrollment period, Melissa turned down the opportunity to get health insurance through her job because it was cheaper to cover herself with a family plan through Ken’s job.
  • Ken’s hours get cut to part-time. Part-time employees don’t get health insurance coverage where Ken works. The entire family loses health insurance coverage. This triggers a special enrollment period for Melissa’s job-based health insurance as well as a special enrollment period on the health insurance exchange in Melissa and Ken’s state.
  • Melissa has a 30 day special enrollment period to sign up for health insurance at her job even though she previously waived that insurance. If she doesn’t act during these 30 days, she won’t be able to sign up at her job until her employer’s next open enrollment period.
  • Melissa’s employer doesn’t offer spousal coverage, so Ken will obtain health insurance at their state’s health insurance exchange. Melissa and Ken have the option to enroll the kids as dependents on Melissa's plan (during the 30-day special enrollment period that applies to her employer's plan), or to enroll them in the plan through the health insurance exchangeThey have a 60 day special enrollment period to enroll in a plan through the exchange (or an individual market plan offered outside the exchange). If they don’t enroll during those 60 days, they won’t have another opportunity to enroll in health insurance through their state’s health insurance exchange until the next annual open enrollment period. The same is true of the individual market plans sold outside the exchange; those plans are compliant with the ACA as well, and have the same enrollment periods and special enrollment periods as the plans sold in the exchange.
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