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What happens if I don't buy coverage during the ACA's open enrollment period?

If you don't enroll in an ACA-compliant health plan by December 15, your buying options – and coverage quality – will be limited.

If you don’t enroll in an ACA-compliant health insurance plan by the end of open enrollment (December 15 in most states, although extended enrollment periods apply in some states), your buying options will likely be very limited for the coming year. Open enrollment won’t come around again until November 2021, with coverage effective the first of the following year.

Where you live determines your enrollment flexibility

State-run exchanges have significant flexibility in terms of the open enrollment schedule. For 2021 coverage, there will be at least 14 fully state-run exchanges, and maybe 15 (Pennsylvania will join the existing 13 fully state-run exchanges; New Jersey is also working towards a fully state-run exchange, but details have not been forthcoming in terms of progress).
State-run exchanges that have their own enrollment platforms are able to extend open enrollment if they choose to do so (states that use cannot; extensions via that platform can only be made by the federal government). In most years, most of the fully state-run exchanges do choose to extend open enrollment. For 2021 coverage, enrollment will be extended in DC, Colorado, California, Pennsylvania, and possibly other states as well.
California’s three-month open enrollment is permanent, under legislation that California enacted in late 2017. Colorado’s extension is also permanent, and so is DC’s.
But in most states and for most enrollees, December 15 is the deadline to enroll in coverage, regardless of whether you’re purchasing a plan through the exchange or outside the exchange (Nevada used to allow year-round enrollment outside the exchange, but that ended as of October 2019). But depending on your circumstances, there are some exceptions that will allow you to enroll outside of open enrollment.

Medicaid enrollment is year-round.

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, with the loss of your Medicaid plan serving as the qualifying event that triggers a special enrollment period.

Native Americans can enroll year-round

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 (SEP). 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).

Under rules that were implemented in 2017, now requires virtually all applicants to provide proof of their qualifying events before being allowed to finalize enrollments outside of open enrollment. And there are also new rules in some cases that limit SEP plan changes to plans at the same metal level the person already has.
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, and know that you might not be able to switch to a more robust plan (eg, from bronze to gold) during your SEP. And understand that in most — but not all — cases, the current SEP rules allow you to change your coverage but not necessarily go from being uninsured to insured. So in some cases, you’re going to have to provide proof of your prior coverage in addition to proof of the qualifying event.
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 coverage options – 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. For most of 2017 and 2018, short-term plans were limited to less than three months in duration, under a rule that was put in place by HHS under the Obama administration. But the Trump administration drastically expanded the definition of short-term plans, in a rule that took effect in October 2018.
The final rule allows short-term plans to have initial terms of up to 364 days (which was the case prior to 2017)and it also allows plans to have a total duration of up to 36 months, including renewals (this part goes beyond just reversing the Obama administration rules) But the majority of the states place more restrictive limits on short-term plans, and those state limits supersede the new federal rules. You can click on a state on this map to see how short-term plans are regulated in the state.
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.
It’s also important to note that short-term/temporary health insurance policies 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 in the individual market (on- or off-exchange), 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, unless you have a separate qualifying event.
Keep in mind that short-term policies are not required to be renewable, although the new federal laws allow insurers to offer renewability. Depending on your state’s regulations and your insurer’s business plan, you may be able to renew your short-term plans, or you may be able to purchase a new short-term policy when your existing one expires. But if you’re buying a new policy, the purchase will require new underwriting, and in most cases, the new policy will not cover pre-existing conditions, including any that began while you were covered under the first short-term policy.

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 Her state health exchange updates are regularly cited by media who cover health reform and by other health insurance experts.

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