qualifying events for obamacare

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Qualifying events that can get you coverage

Open enrollment for 2017 ended January 31, but you can still enroll if you have a qualifying event

  • By
  • healthinsurance.org contributor
  • February 1, 2017

Open enrollment for 2017 ended on January 31 (Minnesota has granted a special enrollment period for all residents; it runs through February 8). In general, the plans available outside of open enrollment without a qualifying event are not regulated by the ACA, and most are not a good choice to serve as stand-alone coverage.

Nevada is an exception. There, off-exchange carriers are required to offer year-round enrollment, but they can impose a waiting period of up to 90 days before benefits become effective.

But in every other state, ACA-compliant plans, both on and off-exchange, are not available for purchase outside of open enrollment. The next open enrollment period will begin November 1, 2017, for coverage effective January 1, 2018, and will end January 31, 2018. This is the same schedule that was followed for 2016 and 2017. But for 2019 plans, open enrollment will run from November 1, 2018, through December 15, 2018, and will remain at that schedule going forward. So starting with plans effective in 2019, open enrollment will end before the start of the benefit year (note that all of this is the currently-scheduled timeframe; under the Trump Administration, changes are likely for the ACA, but it’s likely that the implementation of the bulk of those changes will be delayed until at least 2019).

Qualifying events

Outside of open enrollment, you can still enroll in a new plan if you have a qualifying event that triggers your own special open enrollment (SEP) window.

People with employer-sponsored health insurance are used to both open enrollment windows and qualifying events. In the employer group market, plans have annual open enrollment times when members can make changes to their plans and eligible employees can enroll. Outside of that time frame, however, a qualifying event is required in order to enroll or change coverage.

In the individual market, this was never part of the equation prior to 2014 — people could apply for coverage any time they wanted. But policies were not guaranteed issue, so pre-existing conditions meant that some people couldn’t get coverage or had to pay more for their policies.

All of that changed thanks to the ACA. Individual coverage is now quite similar to group coverage. As a result, the individual market now utilizes annual open enrollment windows and allows for special open enrollment triggered by qualifying events.

So even if you didn’t select a plan by January 31, you could still have an opportunity to enroll in ACA-compliant coverage for 2017 if you experience a qualifying event. In that case, you have a special open enrollment period – generally 60 days – during which you can enroll or switch to a different plan.

Got a qualifying event? You’ll need proof

It’s important to note that HHS began ramping up enforcement of special enrollment period eligibility in 2016, amid concerns that enforcement had previously been too lax.

In February 2016, HHS confirmed that “in the next several months” they would begin requiring proof of eligibility in order to grant special enrollment periods triggered by birth/adoption/placement for adoption, a permanent move, loss of other coverage, and marriage (together, these account for three-quarters of all qualifying events in Healthcare.gov states).

The new SEP eligibility verification process was implemented in June 2016. In September, HHS answered several frequently asked questions regarding the verification process for qualifying events, and noted that SEP enrollments since June were down about 15 percent below where they had been during the same time period in 2015 (after staying roughly even with 2015 numbers in the months prior to implementation of the new eligibility verification process).

But HHS stopped short of issuing an explanation for the decline: it could be that people were previously enrolling who didn’t actually have a qualifying event, but it could also be that the process for enrolling had become more cumbersome due to the added verification step, deterring healthy enrollees from signing up. The vast majority of people who are eligible for SEPs do not enroll in coverage during the SEP, and this could be heightened by the new eligibility verification process.

Starting in June 2017, HHS is planning to implement a pilot program to further enhance SEP eligibility verification (this plan was created by HHS under the Obama Administration; it could change under the Trump Administration). 50 percent of SEP enrollees will be randomly selected for the pilot program, and their enrollments will be pended until their verification documents are submitted. They’ll have 30 days to submit their proof of SEP eligibility, and as long as they do so, their policy will be effective as of the date determined by the date of their application/plan selection (so for example, a person could enroll on July 10 for an August 1 effective date, but the enrollment would then be pended. If the applicant submits proof of SEP eligibility on August 5, the enrollment would be completed, with coverage effective August 1).

The SEP verification pilot program has generated controversy, with some consumer advocates noting that it could further deter healthy people from enrolling when they’re eligible for a SEP. At Health Affairs, Tim Jost suggested some alternative solutions, including a requirement that insurance carriers pay broker commissions for SEP enrollments in order to incentivize brokers to help more people enroll, and a requirement that group health plans provide certificates of creditable coverage to people losing their group coverage (this used to be required, but isn’t any longer; reinstating a requirement that the certificates be issued would make it easier for people to easily prove that they had lost coverage and had thus become eligible for a SEP).

But for the time being, the eligibility pilot program and the enhanced verification are part of the SEP enrollment process in 2017. In the pilot program announcement, CMS noted that “all special enrollment period types will be subject to enhanced verification in some form, whether through the pilot or through other enhanced procedures. In particular, applications based on loss of minimum essential coverage will be included in the pilot.”

State-based exchanges have the option to verify SEP eligibility. Some have implemented verification programs and some have not. But in the vast majority of states, there is at least some form of SEP eligibility verification in 2017. So be prepared to provide proof of your qualifying event when you enroll.

Off-exchange special enrollment periods

Note that most qualifying events apply both inside and outside the exchanges. There are a few exceptions, however. For policies sold outside the exchanges, there are a few qualifying events that HHS does not require carriers to accept as triggers for special enrollment periods (however, the carriers can accept them if they wish). These include gaining citizenship or a lawful presence in the US or being a Native American (within the exchanges, Native Americans can make plan changes as often as once per month, and enrollment runs year-round).

In addition, when exchanges grant special enrollment periods based on “exceptional circumstances” those special enrollment periods apply within the exchanges; off-exchange, it’s up to the carriers as to whether or not they want to implement similar special enrollment periods.

What counts as a qualifying event?

What counts as a qualifying event? In many cases, they’re the same things that count as a qualifying event for employer-based plans. But some are specific to the individual market under Obamacare.

In most cases, the effective date follows the same rules that it does during regular open enrollment. So for states using HealthCare.gov and most of the state-run exchanges, that means that applications completed by the 15th of the month will be given a first-of-the-following-month effective date.

There are three states with enrollment deadlines later than the 15th of the month: Massachusetts, Rhode Island, and Washington are all the 23rd.

Applications received between the 16th (or the 24th if you’re in MA, RI, or WA) and the end of the month will have an effective date of the first of the second following month. (Marriage, loss of other coverage, and birth/adoption have special effective date rules, described below.)

Note that in early 2016, HHS eliminated some little-used special enrollment periods that were no longer necessary (for example, the special enrollment period that had previously been available for people whose Pre-Existing Conditions Health Insurance Program (PCIP) had ended; coverage under those plans ended in 2014).

9 special open enrollment triggers

The qualifying events that trigger special enrollment periods are discussed in more detail in our section devoted to qualifying events and special enrollment periods. But here’s a summary:

  • Involuntary loss of other coverage that is qualified as minimum essential coverage. (Cancelling the plan or failing to pay the premiums does not count as involuntary loss).  Loss of coverage that isn’t minimum essential coverage does not trigger a special open enrollment, but 2014 regulations do provide one exception in the case of loss of pregnancy-related Medicaid coverage.  Women who become ineligible for pregnancy-related coverage do have access to a special open enrollment period. Your special open enrollment begins 60 days before the termination date, so it’s possible to get a new ACA-compliant plan with no gap in coverage. (See details in Section (d)(6)(iii) the code of federal regulations 155.420, and the updated regulation that makes advance open enrollment possible for people with individual coverage as well as employer-sponsored coverage.) You also have 60 days after your plan ends during which you can select a new ACA-compliant plan. If you enroll prior to the loss of coverage, the effective date is the first of the month following the loss of coverage, regardless of the date you enroll (ie, if your plan is ending June 30, you can enroll anytime in May or June and your new plan will be effective July 1). But if you enroll in the 60 days after your plan ends, the exchange can either allow a first-of-the-following-month effective date regardless of the date you enroll, or they can use their normal deadline, which is typically the 15th of the month in order to get a plan effective the first of the following month.
  • Individual plan renewing outside of the regular open enrollment.  HHS issued a regulation in late May 2014 that included a provision to allow a special open enrollment for people whose health plan is renewing – but not terminating – outside of regular open enrollment.  In early 2014, the Obama Administration announced that non-grandfathered pre-2014 individual plans could be extended for up to two more years, and that was further extended in early 2016 to allow those plans to renew as late as October 2017, and continue to exist until the end of 2017; it was left to states and carriers to decide whether or not to do so. The result was that many health plans that were scheduled to terminate at the end of their plan year in 2014 were instead eligible for renewal in 2014, 2015, and 2016 – and that will be the case again in many states for much of 2017. Insureds with these plans may accept the renewal but are not obligated to do so.  Instead, they can select a new ACA-compliant plan during the 60 days prior to the renewal date and 60 days following the renewal date. Initially, this special enrollment period was intended to be used only in 2014, but in February 2015 HHS issued a final regulation that confirms this special enrollment period will be on-going. Thus it will continue to apply to people who have grandfathered plans that renew outside of open enrollment each year.
  • Becoming a dependent or gaining a dependent as a result or birth, adoption, or placement in foster care. Coverage is back-dated to the date of birth, adoption, or placement in foster care (new regulations also allow parents the option to select a later effective date). Because of the special rules regarding effective dates, it’s wise to use a special enrollment period in this case, even if the child is born or adopted during the general open enrollment period.The current regulation states that anyone who “gains a dependent or becomes a dependent” is eligible for a special open enrollment window, which obviously includes both the parents and the new baby or newly adopted or fostered child.But the Federally Facilitated Marketplace accepts applications for the entire family (including siblings) during the special open enrollment window. If you live in a state that is running its own exchange, check with your exchange to see how they have interpreted the regulation.
  • Marriage. If you get married, you have a 60-day open enrollment window that begins on your wedding day. Your policy will be effective the first of the month following your application, regardless of what date you complete your enrollment. Since marriage triggers a special effective date rule, it might make sense to use your special enrollment period if you get married during the general open enrollment period. For example, if you get married on December 27, you can select a new plan that day (or up until the 31st) and have coverage effective January 1 if you use your special enrollment period triggered by your marriage. But if you enroll under the general open enrollment regulations, your new coverage won’t be effective until February 1.
  • Divorce. If you lose your existing health insurance because of a divorce, you qualify for a special open enrollment based on the loss of coverage rule discussed above. If a court orders a parent to obtain health insurance as part of a custody agreement, the exchange must allow the parent the option to backdate the coverage to the date the court order was issued, although the parent can also opt for the normal effective dates described above. Exchanges also have the option of granting a special enrollment period for people who lose a dependent or lose dependent status as a result of a divorce or death, even if coverage is not lost as a result. This special enrollment period was due to become mandatory in all exchanges as of January 2017, but HHS removed that requirement in May 2016, so it’s still optional for the exchanges.
  • Becoming a United States citizen (this qualifying event only applies within the exchanges – carriers selling coverage off-exchange are not required to offer a special enrollment period for people who gain citizenship or lawful presence in the US).
  • A permanent move to an area where different qualified health plans (QHPs) are available. A permanent move to a new state will always trigger a special open enrollment period, because each state has its own health plans. But even a move within a state can be a qualifying event, as some states have QHPs that are only offered in certain regions of the state. However, as of July 11, 2016, this special enrollment period is only available to applicants who already had minimum essential coverage in force for at least one of the 60 days prior to the move (with exceptions for people moving back to the US from abroad, newly released from incarceration, or previously in the coverage gap in a state that did not expand Medicaid).

    So if you move to a part of the state that has plans that were not available in your old area, or if the plan you had before is not available in your new area, you’ll qualify for a special open enrollment period, assuming you had coverage prior to your move.

    HHS finalized a provision in February 2015 that allows people advance access to a special enrollment period starting 60 days prior to a move, but this is optional for the exchanges. It was originally scheduled to be mandatory starting in January 2017 (ie, that exchanges would have to offer a special enrollment period in advance of a move), but HHS removed that deadline in May 2016, making it permanently optional for exchanges to allow people to report an impending move and enroll in a new health plan. If the exchange in your state offers that option, you can enroll in a new health plan on or before the date of your move and the new plan will be effective the first of the following month. If you enroll during the 60 days following the move, the effective date will follow the normal rules outlined above (ie, in most states, enrollments submitted by the 15th of the month will have first of the following month effective dates).

    In early 2016, HHS clarified that moving to a hospital in another area for medical treatment does not constitute a permanent move, and would not make a person eligible for a special enrollment period. And a temporary move to a new location also does not trigger a special enrollment period. However, a person who has homes in more than one state (for example, a “snow bird” early retiree) can establish residency in both states, and can switch policies to coincide with a move between homes (HHS has noted that this person might be better served by a plan with a nationwide network in order to avoid resetting deductibles mid-year, but such plans are not available in all areas).

  • An error or problem with enrollment (or non-enrollment) that was the fault of the exchange, HHS, or an enrollment assister. In this case, the exchange can properly enroll the person (or change plans) outside of open enrollment in order to remedy the problem.
  • Employer-sponsored coverage reducing benefits such that it no longer provides minimum value, or becomes unaffordable (defined as requiring the employee to pay more than 9.69 percent of income for just the employee’s portion of the coverage in 2017).

    In this case, you’ll have access to a special open enrollment window both before and after the date that your employer plan renews – similar to the scenario described above for people losing coverage.

What if you’re already enrolled?

Additional qualifying events apply to people who are already enrolled in the exchange:

  • If your income changes and makes you newly eligible (or ineligible) for premium tax credits or cost-sharing subsidies, you qualify for a special open enrollment. Previous versions of the federal register stated that this open enrollment applied even for people who were not already enrolled in a QHP, but that is incorrect.

    The previous version of the regulation noted that this special open enrollment period only applies to “enrollees” – which means people who already have a plan in the exchange. However, HHS has issued an additional special enrollment period for people who are in states that have not expanded Medicaid, and who have an income change outside of open enrollment that increases their income to at least 100 percent of federal poverty level (ie, they were in the coverage gap, and their income increases to a level that makes them eligible for subsidies in the exchange). This provision allows people who don’t enroll during open enrollment (because they’re in the coverage gap) to enroll later in the year if their income increases.

  • A special open enrollment is available if the insured is enrolled in a QHP that “substantially violated a material provision of its contract in relation to the enrollee.” This does not mean that enrollees can switch to a new plan simply because their existing carrier has done something they didn’t like – it has to be a “substantial violation” and there’s an official channel through which such claims need to proceed.

Who doesn’t need a qualifying event?

In some circumstances, enrollment is available year-round, without a need for a qualifying event:

  • Native Americans/Alaska Natives – as defined by the Indian Health Care Improvement Actcan enroll anytime during the year. Enrollment by the 15th of the month (or a later date set by a state-run exchange) will result in an effective date of the first of the following month. Native Americans/Alaska Natives may also switch from one QHP to another up to once per month (the special enrollment periods for Native Americans/Alaska Natives only apply within the exchanges – carriers selling off-exchange plans do not have to offer a monthly special enrollment period for American Indians).
  • Medicaid and CHIP enrollment are also year-round. For people who are near the threshold where Medicaid eligibility ends and exchange subsidy eligibility begins, there may be some “churning” during the year, when slight income fluctuations result in a change in eligibility.

    If income increases above the Medicaid eligibility threshold, there’s a special open enrollment window triggered by loss of other coverage. Unfortunately, in states that have not expanded Medicaid, the transition between Medicaid and QHPs in the exchange is nowhere near as seamless as lawmakers intended it to be.

  • Employers can select SHOP plans year-round (employees on those plans will have the same sort of annual open enrollment windows as regular employer group plans).

Need coverage at the end of the year?

If you find yourself without health insurance towards the end of the year, you might want to consider a short-term policy instead of an ACA-compliant policy. There are pros and cons to short-term insurance, and it’s not the right choice for everyone. But for some, it’s an affordable solution to a temporary problem. Short term insurance is not considered minimum essential coverage, which means that people who rely on it are subject to the ACA’s individual mandate penalty. But as long as your gap without minimum essential coverage is less than three months (three months is too long), there’s no penalty.

Short-term insurance doesn’t cover pre-existing conditions, so it’s really only an appropriate solution for healthy applicants. And for applicants who qualify for premium subsidies in the exchange, an ACA-compliant plan is also likely to be the best value, since there are no subsidies available to offset the cost of short-term insurance.

But if you’re healthy, don’t qualify for premium subsidies, and you find yourself without coverage for a month or two at the end of the year, a short-term plan is worth considering. You can enroll in a short-term plan for the remainder of the year, and sign up for ACA-compliant coverage during open enrollment with an effective date of January 1. The temporary health plan would certainly be better than going without coverage for the last several weeks of the year, and it would be considerably less expensive than an ACA-compliant plan for people who don’t get premium subsidies.