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13 qualifying life events that trigger ACA special enrollment
Outside of open enrollment, a special enrollment period allows you to enroll in an ACA-compliant plan (on or off-exchange) if you experience a qualifying life event.

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6 lessons Mary Lou Retton’s health scare can teach us about coverage
Mary Lou Retton’s health scare story included some important lessons for consumers, many of whom may assume that the celebrity’s health scare is a sign of barriers to affordable health coverage.
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If I sign up for a Bronze plan during open enrollment, can I bump my coverage up to a higher level several months later if I find out that I need surgery?

If I sign up for a Bronze plan during open enrollment, can I bump my coverage up to a higher level several months later if I find out that I need surgery?

Q. If I sign up for a Bronze plan during open enrollment, can I bump my coverage up to a higher level several months later if I find out that I need surgery?

A. In general no, although it might be possible depending on the circumstances.

If you experience a qualifying event that triggers a special enrollment period (SEP), you may be able to switch to a different plan. But a need for medical care is never a qualifying event, and rules that HHS finalized in 2017 limit the ability to switch to a plan at a different metal level outside of open enrollment.

Plan changes are only possible during open enrollment and special enrollment periods triggered by a qualifying event. These rules apply both on and off-exchange. So regardless of whether you buy your health insurance plan through the exchange/Marketplace or outside the exchange, you won’t have an opportunity to switch to a different plan until the following year (during open enrollment) unless you experience a qualifying event.

And the rules that mostly limit people to plan changes within the same metal level apply to most SEP plan changes. There are some circumstances in which a SEP can be used to switch to a plan at a different metal level, including a person becoming newly eligible for cost-sharing reductions (only available with Silver-level plans) or adding a new family member to the household.1 But in general, plan changes made during a SEP are limited to other plans at the same metal level you already have.

Open enrollment runs from November 1 to January 15 in most states, and allows you to switch to any plan you like, at any metal level. But once open enrollment closes, your ability to switch to a different plan later in the year is sharply limited.


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.

Footnotes

  1. Special Enrollment Period (SEP) Overview for the Federally-facilitated Marketplace. Centers for Medicare and Medicaid Services. April 2020. 

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