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What happens if I don’t buy during the ACA’s OEP?

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

What are your options if you don’t buy during the OEP?


If you don’t enroll in an ACA-compliant health insurance plan by the end of open enrollment (December 15 in most states, although there are nine state-run exchanges that have extended the deadline, and hurricane victims in some counties will have until the end of December), your buying options will likely be very limited for the coming year. Open enrollment won’t come around again until next November, with coverage effective the first of the following year.

Where you live determines your enrollment flexibility

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.)

And for 2018 coverage only, state-run exchanges have significant flexibility in terms of the open enrollment schedule. Nine state-run exchanges have announced extensions that range from December 22 to January 31.

Hurricane victims in some counties in Georgia, Florida, and Texas will have until the end of December to enroll. And people whose coverage is terminating at the end of 2017 due to an insurer leaving the market will have a special enrollment period due to loss of coverage.

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. 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.

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, 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).

Soon after Tom Price took over as Secretary of HHS, the agency 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. 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.

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 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. As of 2017, short-term plans are limited to less than three months in duration, but that is a rule that was put in place by HHS under the Obama Administration, and the Trump Administration has already taken steps to reverse it.

Prior to 2017, the federal definition of short-term plans was coverage with a duration of up to 364 days, although states could and did set more restrictive limits. The regulations changed under Obama Administration regulations finalized in 2016 and effective in 2017. But Trump signed an executive order in October 2017, directing federal agencies to consider crafting regulations that would roll back the new limitation on short-term plans. The process of doing so would require a proposed notice and public comment period, so it won’t happen overnight. But it’s likely that at some point in 2018, short-term plans will once again be allowed to have durations of up to a year in many states.

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 loss of other health insurance that is considered minimum essential coverage is a qualifying event that triggers a special open enrollment period, 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 renewable. Depending on your state’s regulations, you may be able to purchase a new short-term policy when your existing one expires, but that purchase will require new underwriting, and the new policy will not cover pre-existing conditions, including any that began while you were covered under the first short-term policy.

Beware the individual mandate penalty

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.

In 2016, the penalty for not having health insurance was $695 per adult (half that amount per child) or 2.5 percent of household income, whichever is greater. It has remained at that level for 2017, although the flat-rate penalty is expected to increase for 2018. Eliminating the penalty is a key part of the Republican plan to repeal and replace the ACA, but the repeal effort has ended for 2017 with the ACA intact.