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Miss open enrollment? You’ve got options.

If you missed open enrollment, your health insurance options are limited, but you can still get coverage if you have an extension or a SEP, and short-term plans are available year-round

Open enrollment for 2018 coverage ended on December 15, 2017 in most states, marking the first time that open enrollment ended before the start of the new year. By December 23, about 11.6 million people had enrolled in exchange plans for 2018 across the country, in addition to an unknown number of people who had selected off-exchange plans (these are not tracked as closely as on-exchange plans, but nearly 6 million people had off-exchange ACA-compliant coverage in 2017).

Enrollment volume was heavy in the final days of open enrollment, and HealthCare.gov was taking names of last-minute callers, so they could call them back after December 15 to finalize their enrollment. But there are undoubted some people who missed the boat.

But if you still don’t have health insurance lined up for 2018, you may still be in luck if you’re trying to obtain ACA-compliant coverage.

If your insurer exited the market, you’re eligible for a special enrollment period

Involuntary loss of coverage is a qualifying event that triggers a special enrollment period (SEP), on or off-exchange. The special enrollment period starts 60 days before the loss of coverage, and continues for 60 days afterward. At the end of 2017, there were numerous insurers around the country that exited the exchanges in various states (and in some cases, the entire individual market). Some of these insurer exits had very little impact, like CeltiCare’s exit from the Massachusetts exchange. But others resulted in tens of thousands of people needing to select new plans, like BlueKC’s exit from the individual market in Missouri, and Aetna’s exit in Nebraska.

If you had a plan through the exchange and your insurer exited the market in your area at the end of the year, the exchange likely picked a new plan for you if you didn’t pick one yourself during open enrollment (note that state-run exchanges are not required to do this. For example, Cigna enrollees in Maryland’s exchange were not mapped to a new plan for 2018 — if they didn’t pick their own new plan, they were uninsured as of January 1).

But CMS also confirmed that these enrollees are still eligible for a SEP triggered by loss of coverage. That SEP has effective date rules that differ from the normal rules: If your 2017 insurer left the market in your area, you had the option to pick a new plan as late as December 31, 2017 and have your new coverage be effective January 1, 2018. Your SEP continues until March 1, 2018, but if you’re enrolling after December 31, you’ll have a delay before your new plan replaces the one that the exchange picked for you (again, state-run exchanges have some flexibility on this. Idaho’s exchange confirmed that they would map BridgeSpan members to new plans, as well as SelectHealth members in areas where the insurer was discontinuing plans. But they also clarified that they would not offer a special enrollment period for those members. If you’re a state-run exchange, your mileage may vary in terms of this SEP if your exchange mapped you to a new plan).

If you had a plan outside the exchange and your insurer exited the market at the end of the year, you also have until March 1, 2018 to pick a new plan, and this applies in every state, regardless of who runs the exchange in your state (since there’s no entity that can map you to a new plan if you have off-exchange coverage and your insurer exits the market). But if you didn’t pick your own replacement plan by December 31, 2017, you were uninsured as of January 1. Your SEP will continue until March 1, but you’ll have a gap in coverage at the start of 2018 if you didn’t enroll by December 31, 2017.

To clarify, the SEP for loss of coverage applies if your insurer is exiting the market altogether in your area, or making a dramatic change to the available plans (such as switching everyone from PPOs to HMOs, for example). But it would not apply if your insurer just makes minor changes to your coverage, such as changing the deductible or copay amounts.

Native Americans and people eligible for Medicaid/CHIP can enroll year-round

Native Americans can enroll in exchange plans year-round. And people who qualify for Medicaid or CHIP can also enroll at any time.

A qualifying event at any time of the year will allow you to enroll in a plan (with some limitations)

Applicants who experience a qualifying event gain access to a special open enrollment window to shop for plans in the exchange (or off-exchange, in most cases) with premium subsidies available in the exchange for eligible enrollees.

HHS stepped up enforcement of special enrollment period eligibility verification in 2016, and further increased the eligibility verification process in 2017. So if you experience a qualifying event, be prepared to provide proof of it when you enroll. And although a permanent move to an area where different health plans are available used to trigger a SEP regardless of whether you had coverage before the move, that’s no longer the case. You must have coverage in force before your move in order to qualify for a SEP in your new location.

But without a qualifying event, health insurance is not available outside of general open enrollment, on or off-exchange. (Nevada is an exception: off-exchange plans in Nevada are available for purchase year-round, but the carrier can impose a 90-day waiting period before coverage takes effect).

Unfortunately, this fact has caught many people by surprise over the last few years. And the open enrollment schedules have changed nearly every year for the first five years of ACA implementation, which further added to the confusion. The first open enrollment period was six months long; the second and third were both three months, but the dates were different. And while the fourth open enrollment period followed the same schedule as the third, the fifth (for 2018 coverage) was dramatically shorter than open enrollment had been in prior years.

New open enrollment schedule may have caught people off guard

For 2018, HHS had originally planned to keep the same November 1 – January 31 schedule, but a market stabilization rule finalized in April 2017 shortened open enrollment for 2018, scheduling it to run from November 1 to December 15 in 2017 (the same schedule that was already planned for 2019 coverage and beyond). The change was not without controversy, as there was disagreement in terms of whether the shorter open enrollment period for 2018 coverage would ultimately have a market stabilizing effect. California’s Insurance Commissioner, for example, believes it will do the opposite (California is one of three state-run exchanges that opted to keep the full three-month open enrollment period for 2018 coverage).

Compounding the shorter open enrollment period was the Trump Administration’s decision to drastically cut funding for outreach, marketing, and enrollment assistance for the federally-run exchange. Although the Obama Administration had already planned to switch to a shorter enrollment period in the fall of 2018, the assumption was that a Democratic administration would have maintained or increased federal funding to support enrollment — they almost certainly would not have cut it.

However, despite the shorter open enrollment period and the drastic reduction in federal funding for outreach and marketing, enrollment in HealthCare.gov ended up only slightly lower than it had been in 2017. Grassroots advocates across the country worked to educate people about open enrollment and the options available to them, and the larger premium subsidies (due to the way the cost of cost-sharing reductions was added to silver plan premiums in most states) made coverage for 2018 more affordable than it had been in past years for millions of enrollees.

Short-term insurance: the closest thing to “real” insurance if you missed open enrollment

For people who didn’t enroll in coverage by the end of open enrollment and who aren’t expecting a qualifying event later in the year (or at the start of the year triggered by loss of coverage at the end of 2017), the options for 2018 coverage are limited to policies that are not regulated by the ACA. This includes short-term health insurance, some limited-benefit plans, accident supplements, critical/specific-illness policies, dental/vision plans, and medical discount plans.

Some of these policies are a good supplement to regular major medical health insurance. But most of them are not a good option to serve as stand-alone medical coverage—except short-term health insurance, which is available in all but five states.

Short-term coverage is the closest thing you can get to “real” health insurance if you find yourself needing to purchase a policy outside of open enrollment without a qualifying event. Since March 31, 2017, short-term plans have been capped at three months in duration, due to an Obama Administration regulation that was finalized in late 2016 and took effect in 2017. This regulation is still in place, but HHS has proposed new rules that, if finalized, would reverse it as of mid-2018.

The Obama-Administration HHS implemented the regulation to cap short-term plans at three months in an effort aimed at “curbing abuse” of short-term plans. At that point, under HHS Secretary Sylvia Matthews-Burwell, HHS noted that short-term plans are exempt from having to comply with ACA regulations specifically because they’re supposed to only be used to fill gaps in coverage — but instead, people had been using them for up to a year at a time, which effectively removes healthy people from the ACA-compliant risk pool, destabilizing it over the long-run.

In 2017, several GOP Senators asked HHS to reverse this regulation and go back to allowing short-term plans to be issued for durations up to 364 days. And the Trump Administration confirmed their commitment to rolling back the limitations on short-term plans in an October 2017 executive order. The proposed rule that was published by HHS on February 20, 2018 (in response to Trump’s executive order) calls for reverting to the pre-2017 definition of “short-term,” when those plans could remain in place for up to 364 days (many states capped them at six months, and states will still have the authority to do so if the new rules are implemented).

HHS is taking comments on the proposed rule until April 23. After that, the changes to the definition of “short-term” would take effect 60 days after the rule is finalized. So longer short-term plans could be available to consumers as early as July 2018.

But for the time being, short-term plans are still limited to no more than three months in duration. However, depending on where you live, you might be able to purchase up to four back-to-back short-term plans with one application, effectively gaining access to nearly a year of short-term coverage despite the current regulations (consumers need to be aware that while a condition that develops during the first policy term would continue to be covered by the rest of the pre-purchased policies, the deductible and out-of-pocket maximum would reset at the end of each three-month policy).

Although premium subsidies are not available for short-term plans, the retail prices on these policies are more affordable than the retail price (ie, unsubsidized) on ACA-compliant plans, and they do still serve as a good stop-gap if you just need a policy to cover you for up to three months when you’re in between other policies. However, if your income makes you eligible for the Obamacare premium subsidies, it’s essential that you enroll through your state’s exchange during open enrollment (or a special enrollment period triggered by a qualifying event like losing access to your employer-sponsored health insurance); otherwise, you’re missing out on comprehensive health insurance and a tax credit.

Some short-term plans have provider networks, but others allow you to use any provider you choose. Unlike ACA-compliant plans, short-term policies have benefit maximums. But the limits tend to be more reasonable than the infamous “mini-med” plans that barely covered a few nights in the hospital.

Lifetime maximums of $750,000 to $2 million are common on short-term plans. While this is not as good as regular individual insurance plans that no longer have annual or lifetime benefit caps, it’s roughly similar to a lot of the plans that were available just a few years ago in the individual market. And the concept of a “lifetime” limit doesn’t really matter when you’re talking about a plan that lasts for at most 364 days (if and when the new regulations are finalized), since you won’t be able to purchase another short-term plan if you develop a serious health condition.

Short-term coverage application: an easy process, but pre-existing conditions are not covered

The application process is very simple for short-term policies. Once you select a plan, the online application is much shorter than it is for standard individual health insurance, and coverage can be effective as early as the next day.

There are no income-related questions (since short-term policies are not eligible for any of the ACA’s premium subsidies), and the medical history section is generally quite short – nowhere near as onerous as the pre-2014 individual health insurance applications were.

Keep in mind that although the medical history section generally only addresses the most serious conditions in order to determine whether or not the applicant is eligible for coverage, short-term plans all have blanket disclaimers stating that no pre-existing conditions are covered.

To be clear, short-term plans are not as good as the ACA-regulated policies that you can purchase during open enrollment or during a special enrollment period. Short-term insurance is not regulated by the ACA, so it doesn’t have to follow the ACA’s rules:

  • The plans still have benefit maximums, and they are not required to cover the ten essential benefits. (Most often, short-term plans don’t cover maternity, preventive care, or mental health/addiction treatment), they do not have to limit out-of-pocket maximums, and they do not cover pre-existing conditions. They also still use medical underwriting, so coverage is not guaranteed issue.
  • And the plans are not renewable. In most states, you have the option to apply for a new policy after the first one ends (the second policy would also be capped at no more than three months in duration), but you’ll be going through the application process as a new enrollee, and any health conditions that developed while you were covered by the first policy would be considered pre-existing conditions under the second policy.

(Also, many short-term plans do not cover prescriptions. Using a pharmacy discount card may lower medication costs without health insurance, and some discount prices may be lower than an insurance copay.)

Not a qualifying event: losing short-term coverage

Although loss of existing minimum essential coverage is a qualifying event that triggers a special open enrollment period for ACA-compliant plans, short-term policies are not considered minimum essential coverage, so the loss of short-term coverage is not a qualifying event. Let’s say you lose your job and your employer plan ends at the end of July. You then have a 60-day window during which you can enroll in an ACA-compliant plan.

You also have the option to buy a short-term plan that could cover you for August, September, and October. But when the short-term plan ends, you would no longer have access to an ACA-compliant plan (you’d have to wait for open enrollment, and a plan selected during open enrollment would become effective on January 1) and although you could purchase another short-term plan, your eligibility would again depend on your current medical history.

In addition, since short-term health insurance is not considered minimum essential coverage, you’ll still be on the hook for the ACA’s shared responsibility penalty if you rely on a short-term plan for your coverage. There’s an exemption from the penalty if you only have a short gap in coverage that lasts no more than two months (you could have a short-term plan during that two months and would not be subject to the penalty).

The penalty is still in place as of 2018, but it will no longer apply in 2019 or beyond, as it was repealed (effective in 2019) in the GOP tax bill that was implemented in 2017.

Be aware that the penalty got much higher in 2016, although it has remained at the same level for 2017 and 2018 (the flat-rate penalty was scheduled to be indexed for inflation starting in 2017, but the inflation adjustment was zero for 2017 and was again zero for 2018). For 2017, and again for 2018, the penalty is the greater of: $695 per uninsured adult (half that amount for a child), up to $2,085 for a household, OR 2.5 percent of household income above the tax filing threshold. The penalty is prorated for the number of months you’re uninsured or covered by a policy that’s not minimum essential coverage (like a short-term plan).

Although short-term plans do not provide the level of coverage or consumer protections that the new ACA-compliant plans offer, obtaining a short-term policy is better than remaining uninsured. But your best bet is to maintain coverage under an ACA-compliant policy; if you’re not enrolled, you’ll want to do so if you experience a qualifying event (most people don’t take advantage of their qualifying events, perhaps unaware that their opportunity to enroll is 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.