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.
Nevada allows people to enroll outside the exchange (ie, directly through a health insurance company) year-round, but with a 90-day waiting period if you enroll after open enrollment has ended (and bear in mind that there are no subsidies available outside the exchange).
But in most states, December 15 is the deadline to enroll in coverage, regardless of whether you’re purchasing a plan through the exchange or outside the exchange. 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 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).
(If you’re uncertain about your eligibility for a special enrollment period, call (844) 428-3344 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. It’s unclear whether the various proposals and changes made by the Trump Administration will be stabilizing or destabilizing for the markets, but in terms of special enrollment periods, HealthCare.gov now requires virtually 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 in general, 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 (unless you’re in Nevada, where all off-exchange plans are available year-round with a 90-day waiting period).
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 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 and continue to be medically underwritten and provide no coverage for pre-existing conditions. Short-term plans are limited to less than three months in duration, but that is a rule that was implemented by HHS under the Obama Administration. The Trump Administration has finalized new regulations that will allow longer short-term plans to once again be sold (at the discretion of each state) as of late 2018.
The rule was finalized in early August, and will take effect 60 days after it’s published in the Federal Register. Once the new rules are in place, short-term plans will be available with initial terms up to 364 days in states that allow that duration (some states do not). Some insurers will offer guaranteed renewability, and the new rules allow a single plan to remain in force for up to 36 months, including the initial term and subsequent renewals. With the longer terms and the option to renew (which some insurers will offer and some won’t), short-term plans will become a better option than they currently are for people who are uninsured and missed open enrollment. An ACA-qualified plan will continue to be a better choice, but if you miss open enrollment and/or you can’t afford an ACA-qualified plan, a short-term plan is a much better option than remaining uninsured.
It’s also important to note that short-term / temporary health insurance policies have set expiration dates. And while 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 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. If you opt to have coverage through a supplemental or discount plan or a short-term policy, you’ll still be subject to the shared responsibility penalty unless you qualify for an exemption. The penalty continues to apply in 2018 for people who are uninsured, but it will be eliminated as of 2019 (so people who file taxes in early 2019 will still have to pay the penalty for being uninsured in 2018, but there will no longer be penalties assessed when 2019 tax returns are filed in early 2020).
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.