Q. If I don’t enroll in a health insurance plan by the end of open enrollment (December 15), what options will I have?
A. In most cases, your options will be very limited for the coming year if you don’t enroll in coverage by December 15 (unless you’re in a state where the enrollment deadline is extended). Open enrollment won’t come around again until the following November, with coverage effective the following January.
The open enrollment period — which ends December 15 in most states — applies outside of the exchange as well.
Depending on your circumstances, however, there are some exceptions that will allow you to enroll outside of open enrollment.
Medicaid enrollment is available year-round for those who qualify. If your income drops to a Medicaid-eligible level later in the year, you’ll be able to enroll at that point. Similarly, if you’re on Medicaid and your income increases to a level that makes you ineligible for Medicaid, you’ll have an opportunity to switch to a private plan at that point.
Native Americans can enroll in plans through the exchange year-round. Here’s more about special provisions in the ACA that apply to Native Americans.
Special enrollment period
If you have a qualifying event during the year, you’ll have access to a special enrollment period. Qualifying events include things like marriage (assuming at least one spouse already had coverage prior to the marriage), the birth or adoption of a child, loss of other minimum essential coverage, or a permanent move to a new geographical area where the available health plans are different from what was available in your prior location (assuming you already had coverage prior to your move). Our guide to special enrollment periods in the individual health insurance market explains all of the qualifying events and the rules that apply to each one.
(If you’re uncertain about your eligibility for a special enrollment period, call (800) 436-1566 to discuss your situation with a licensed insurance professional.)
In 2017, HHS implemented a variety of changes aimed at market stabilization, particularly for the individual market. HealthCare.gov now requires all applicants to provide proof of their qualifying events before being allowed to finalize enrollments outside of open enrollment. The state-run exchanges can use their own discretion on this, but do tend to require proof of all qualifying events. So if you’re enrolling mid-year, be prepared to provide proof of the qualifying event that triggered your special enrollment period.
If you do not have a qualifying event, there is no way to enroll in an ACA-qualified individual health insurance policy outside of normal open enrollment, either on or off-exchange. This is very different from the pre-2014 individual health insurance market, where people could apply for coverage at any time. But of course, approval used to be contingent on health status, which is no longer the case.
Other plans – and their limits
Unless you have a qualifying event or become eligible for Medicaid or employer-sponsored coverage, the only plans you can purchase outside of open enrollment are those that are not deemed minimum essential coverage.
This includes discount plans, critical illness coverage, dental and vision plans, accident supplements, and short-term medical insurance policies. Of the plans that are available outside of open enrollment, short-term policies are probably the best coverage option, but they should not be considered a good substitute for an ACA-qualified plan.
Although ACA-qualified policies are all guaranteed issue during open enrollment and special enrollment periods, short-term policies are not regulated by the ACA. They continue to be medically underwritten and provide no coverage for pre-existing conditions. Under federal rules that took effect in late 2018, short-term health insurance plans can have initial terms of up to 364 days, and total duration, including renewals, of up to three years. But more than half of the states have stricter limits for short-term health plans, either banning them altogether or limiting them to shorter durations. In the states that defer to the federal rules, some insurers offer 364-day terms and guaranteed renewability, while others choose to only offer shorter terms and/or non-renewable plans.
So if you missed open enrollment and are hoping to enroll in a short-term health insurance plan as a substitute for real individual major medical coverage, the availability of this option will very much depend on where you live and how healthy you are. Short-term medical plans are not ideal, but they are a much better option than remaining uninsured.
It’s important to understand that short-term plans are, by definition, temporary health insurance policies, and they have set expiration dates. And while the loss of other health insurance that is considered minimum essential coverage is a qualifying event that triggers a special open enrollment period for ACA-compliant individual market plans, short-term policies are not minimum essential coverage. So you will not be able to purchase an ACA-compliant plan outside of open enrollment when your short-term policy expires (you would, however, be able to join your employer’s plan when your short-term plan ends, as the termination of a short-term plan is a qualifying event for employer-sponsored coverage; HHS clarified that point in the new rules for short-term plans).
Discount plans and supplemental policies tend to be guaranteed issue, but their coverage is gossamer thin and provides no cap on out-of-pocket exposure.
The plans available outside of open enrollment (without a qualifying event) will provide meager coverage compared with the ACA-qualified plans that are sold on and off-exchange. And purchasing them will not satisfy the individual mandate in states that still impose a penalty for not having health insurance coverage (New Jersey, Massachusetts, California, Rhode Island, and the District of Columbia).
Louise Norris is an individual health insurance broker who has been writing about health insurance and health reform since 2006. She has written dozens of opinions and educational pieces about the Affordable Care Act for healthinsurance.org. Her state health exchange updates are regularly cited by media who cover health reform and by other health insurance experts.