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Are qualifying events and special enrollment periods the same as they were in prior years?


Q. Are qualifying events and special enrollment periods the same as they were in prior years?

A. For the most part, yes. Outside of open enrollment, you’ll need a special enrollment period (SEP), triggered by a qualifying event, to enroll in an ACA-compliant health plan. The extensive list of qualifying events is mostly the same as it was in 2014, although there have been a few changes and verification of eligibility is much more strongly enforced than it was in the early years of ACA-compliant plans.

Permanent changes

In November 2014, HHS proposed a series of changes and modifications to the existing special enrollment period guidelines (45 CFR section 155.420), and the final regulations were issued February 2015.  Several new or modified SEPs were included in the final regulations, and some additional changes have been made since then:

  • One of the most important new SEPs that took effect in 2015 applies to people who live in states that haven’t expanded Medicaid and are currently in the coverage gap because their incomes are under the federal poverty level. (They can’t get Medicaid because their states haven’t expanded eligibility, and their incomes are too low for subsidies in the exchange.) This SEP allows them to purchase subsidized coverage in the exchange as soon as their income increases to at least 100 percent of the poverty level. (Under normal circumstances, a change in income is not a qualifying event, but this SEP creates an exception.)
  • If a court order requires a parent to purchase health insurance as part of a child support agreement, the exchange will make coverage effective the date the court order is effective, in order to prevent gaps in coverage.  But the enrollee still has the option to select an effective date based on the normal guidelines (in most states, that would mean a plan selected by the 15th of the month would be effective the first of the following month).
  • For 2014, HHS created a SEP for people who had existing coverage with plan years that ended outside of open enrollment. (This could be group plans, or individual policies that were grandmothered or grandfathered.) That SEP was originally intended to apply only in 2014, but this SEP now applies in any year, for anyone who has a non-calendar-year plan that is up for renewal (or is expiring).  Instead of renewing the existing plan, the person would have the option to enroll in an exchange plan at that point.  HHS clarified that this SEP also applies in the off-exchange market.
  • Moving to a new location where different QHPs are available has been a SEP since 2014. But HHS subsequently added new requirements that took effect in July 2016. As of that date, a SEP is only available following a permanent move if the applicant had minimum essential coverage in place for at least one of the 60 days prior to the move. So essentially, you can’t move in order to obtain health insurance; you must already have coverage in place prior to the move, or the SEP doesn’t get triggered.
  • In April 2017, HHS finalized a market stabilization rule that addressed a wide range of issues. One of the provisions of the new rule prohibits enrollees from using a SEP to switch to a plan at a higher metal level. This is to ensure that in general, people remain in the same metal level throughout the year, and aren’t able to use a SEP to switch to a significantly more robust plan, potentially at the same time that they also need more medical care.

One-Time SEPs

COBRA enrollees had a one-time SEP in 2014 during which they could switch to an exchange plan. That’s not available anymore. COBRA enrollees who want an individual health insurance plan outside of open enrollment will have to wait until they have a qualifying event during the year (including loss of coverage when COBRA is exhausted).

However, a modification was made in late 2016 to the rules surrounding the SEP for people whose employer-sponsored coverage is ending and who have the option to elect COBRA. Previously, the SEP in the individual market (on or off-exchange) ended if and when the person elected COBRA. But HHS realized that some people were electing COBRA at their exit interviews or very soon after leaving their jobs, without really understanding the available options in the individual market (including premium subsidies in the exchange, if the person is eligible based on income). So in late 2016, they modified the rules to ensure that people who lose access to an employer-sponsored plan would have a full 60 days to select a plan in the individual market, regardless of whether they initially elect COBRA or not. A person who elects COBRA five days after leaving a job would be able to change her mind and switch to a plan in the individual market, as long as she does it within 60 days of when her employer-sponsored plan would have ended if not for her COBRA election.

There was also a one-time SEP in the spring of 2015 for people who found out when they filed their taxes that they owed a penalty for being uninsured in 2014. This SEP applied to people in the 37 states where HHS was running the exchange (HealthCare.gov) at that point, and all but three of the state-run exchanges also offered a similar SEP. However, this SEP was only offered in 2015, and is no longer available.

Things that still don’t trigger a SEP

Consumer advocates have pushed for a SEP triggered by pregnancy that would allow an uninsured woman to enroll if a health insurance plan if she finds out that she’s pregnant.  In the final regulations published in February 2015, HHS noted that they had considered this possibility, but ultimately did not include it in the new SEP guidelines.  They left the door open for the possibility that it could be added at a later date, or added by individual states (New York has since done so).

There have also been calls for a SEP based on inaccurate provider network lists, or provider networks being changed mid-year.  HHS has clarified that they are not implementing such a SEP because the logistics would be too complicated. But they noted that in some circumstances, a SEP might apply if the carrier “substantially violates their contract with the enrollee” (note that provider directories are not required to remain unchanged throughout the year; for a contract violation to have occurred, it would require a more substantial issue than this).

Who doesn’t need a special enrollment period?

For a more expansive explanation of these qualifying events, read Qualifying events that can get you coverage, and see our detailed section-by-section explainer of special enrollment periods.