Exceptional circumstances for special enrollment

In addition to the qualifying events already discussed in the previous sections, there are a range of other circumstances that will allow you to enroll in a health insurance plan through the exchange after open enrollment has ended for the year.

An executive order signed by President Biden has authorized a COVID-related special enrollment period on HealthCare.gov, for Americans who don’t currently have health coverage. The SEP will run from February 15 to August 15.

These are all case-by-case situations that will vary by location and year, and they all apply on-exchange — although off-exchange carriers can allow for enrollment flexibility for these situations too.

Special enrollment period related to COVID pandemic

The COVID-19 pandemic is uncharted territory for the United States, but it’s an excellent example of an exceptional circumstance that can trigger a special enrollment period. More than 27 million Americans have no health insurance coverage, which immediately presented an obstacle to the nation’s ability to fight the virus. To ensure that as many people as possible would be able to have coverage as the nation faced this crisis, most of the state-run exchanges announced special enrollment periods in 2020, under which uninsured residents could select a plan, even if they didn’t have a qualifying event.

Under the Trump administration, HealthCare.gov did not open a COVID-related special enrollment period in 2020, although they did modify the loss-of-coverage special enrollment period requirements to allow people to use it if they had lost their health coverage at any point back as far as January 1, 2020.

But soon after taking office, the Biden administration created a special enrollment period in the 36 states that use HealthCare.gov, giving uninsured Americans another opportunity to enroll in coverage, and providing $50 million in funding to publicize the enrollment period and make sure people know about it. The new COVID-related special enrollment period began February 15 and continues through August 15, 2021 (note that this is an extended deadline; it was originally scheduled to end in May), and can be used by people who are uninsured as well as people who are already enrolled in a marketplace plan and would like to switch to a different plan. It’s also an excellent opportunity to take advantage of the new premium subsidies made available by the American Rescue Plan.

The new COVID special enrollment period applies in all of the states that use HealthCare.gov, but all 15 fully state-run exchanges have followed suit, or had already announced COVID-related special enrollment periods before HealthCare.gov’s was announced. Here are the current enrollment deadlines for COVID-related special enrollment periods in states that run their own exchanges (note that these have been extended various times and are possibly still subject to additional extensions in some states):

• All 36 states that use HealthCare.gov: Through August 15
• California: Through December 31
• Colorado: Through “at least” August 15
• Connecticut: Through August 15
• DC: Through the end of the pandemic emergency period
• Idaho: Through April 30 (ended; a qualifying event is now necessary in order to enroll or change plans)
• Maryland: Through August 15 (retroactive coverage is available, depending on when a person enrolls)
• Massachusetts: Through July 23
• Minnesota: Through July 16 (for uninsured residents and people transitioning from off-exchange to on-exchange coverage)
• Nevada: Through August 15
• New Jersey: Through December 31
• New York: Through December 31
• Pennsylvania: Through August 15
• Rhode Island: Through August 15
• Vermont: Through October 1 (for uninsured residents)
• Washington: Through August 15

Some of these enrollment opportunities are only available to uninsured residents or people who don’t already have coverage through the exchange, but most apply to anyone eligible to use the marketplace, including people who already have coverage and want to switch to a new plan.

Other exceptional circumstances, including natural disasters

“Exceptional circumstances” can be personal – for example, a house fire or a serious medical condition that made it impossible for you to enroll – but they also include natural disasters that impact a large number of people. They can also be triggered by political or regulatory changes.

If exceptional circumstances occur during open enrollment (or in some cases, prior to open enrollment), and you can demonstrate to the exchange that the circumstances prevented you from enrolling by the end of open enrollment, the exchange can grant you a special enrollment period. This also applies if the exceptional circumstance happened before or during another special enrollment period for which you were eligible, and it essentially extends your special enrollment period.

HHS issued guidance in 2018 explaining how special enrollment periods work via HealthCare.gov in areas where FEMA declares a disaster that allows a county to apply for “individual assistance” or “public assistance” as a result of the disaster.

The special enrollment period continues for 60 days after the FEMA disaster incident period ends, and applicants can select an effective date in the future or the effective date they would have had if they’d enrolled during the open enrollment period (ie, a January 1 effective date).

In order to be eligible for this special enrollment period, you have to contact HealthCare.gov (800-318-2596 or TTY at 855-889-4325) and attest to the fact that COVID-19 prevented you from enrolling in a health plan during the open enrollment period (or a special enrollment period that you were eligible for due to a qualifying event). These special enrollment period requests are evaluated on a case-by-case basis, and you may be asked to provide various documentation to clarify how the pandemic impacted your ability to sign up during open enrollment.

To give an example of how this works, we’ll consider the 2020 hurricane season. Hurricanes Laura and Marco caused extensive damage in Texas and Louisiana in August 2020. But since that was not during the annual open enrollment period (November 1 – December 15), residents in affected areas were only eligible for a special enrollment period if they had already qualified for a special enrollment period — due to some other qualifying event — that was ongoing during the hurricane, and were unable, because of the hurricane, to complete their enrollment by the end of that SEP.

Among the states that use HealthCare.gov (and thus have the aforementioned 60-day window after the end of a FEMA-declared disaster incident), there were several weather-related events in the summer and fall of 2020, but most of them had an incident period that ended more than 60 days prior to December 15, so they didn’t result in additional time for people to enroll after the end of open enrollment. But there were three incidents that still had ongoing special enrollment periods for affected individuals as of mid-December 2020 (ie, after open enrollment had ended in states that use HealthCare.gov):

• Hurricane Zeta in southeastern Mississippi: Incident period ended October 29, so special enrollment period continued through December 28.
• Tropical Storm Zeta in Louisiana (statewide): Incident period ended October 29, so special enrollment period continued through December 28.
• Hurricane Eta in 13 Florida counties: Incident period ended November 12, so special enrollment period continued through January 11, 2021.
• Wildfires and winds in much of western Oregon: Incident period ended November 3, so special enrollment period continued through January 2, 2021.

[There were other FEMA-declared disasters in states that have their own marketplaces (for example, extensive wildfires in Colorado), but most of the state-run marketplaces had extended open enrollment deadlines anyway, making it unnecessary to add extra time specifically for people who were affected by a natural disaster.]

As was the case in prior years, the special enrollment period applies to people living in areas deemed eligible for public assistance or individual assistance, and the applicant has to attest that they were affected by the emergency or disaster and it prevented them from enrolling during the regular open enrollment period or the other special enrollment period for which the person was eligible (for example, if you lose your employer-sponsored health insurance and qualify for a SEP but then a tornado hits your town and you’re unable to enroll during your SEP, you’ll have another SEP that continues for 60 days after the tornado, assuming your area qualifies for FEMA assistance).

The applicant can choose to use regular effective date rules (with an effective date of the first of the following month or the first of the second following month), but they also have the option to get a retroactive effective date that would have applied if they had enrolled during the regular open enrollment period or their initial special enrollment period, as long as that application date would have been after the FEMA-declared incident began. Table 1 in the federal guidance shows some example scenarios of possible effective dates when people experience a FEMA-declared disaster during another special enrollment period or during the annual open enrollment period.

(If you’re uncertain about your eligibility for a special enrollment period, call (800) 436-1566 to discuss your situation with a licensed insurance professional.)

Domestic violence or spousal abandonment

Victims of domestic violence or spousal abandonment are eligible to enroll in a plan on their own (or with their children), separate from the partner who abused and/or abandoned them. This is true regardless of whether the abuse or abandonment happens outside of open enrollment

Under normal circumstances, married enrollees are only eligible for subsidies in the exchange if they file a joint tax return, and their exchange enrollment must include total household income. But there’s an exception for victims of domestic violence or spousal abandonment. In those circumstances, the victim can state that he or she is unmarried on the exchange application, and eligibility for premium subsidies and cost-sharing subsidies will be calculated based on the enrollee’s income alone.

Enrollment errors and delays

There are a variety of errors and delays that could occur during the regular open enrollment period. To provide flexibility for the exchanges to deal with these issues, HHS included them in the category of qualifying events:

• Your enrollment – or lack thereof – was the result of an error, misrepresentation, misconduct, or inaction on the part of the exchange, one of its representatives, or an enrollment assister. It’s a good idea to keep notes with details about the steps you take to enroll during open enrollment, so that you have documentation in the event that you need to show that errors occurred. This sort of scenario doesn’t happen too often now that the exchanges have had a few years to work out most of their bugs, but mistakes can still happen, and a special enrollment period to sort out the problems is an important safeguard.

• Your eligibility determination (for Medicaid/CHIP, premium subsidies, and/or cost-sharing subsidies) or coverage effective date was incorrect, and you filed a successful appeal with the exchange. If the appeal process finds that the initial eligibility determination and/or effective date were incorrect, you’ll have an opportunity to enroll again with the correct information, even if open enrollment has ended by that point.

• A technical error occurred during your enrollment, or the plan information was incorrectly displayed on the exchange website.

• You’re a recent immigrant (not eligible for Medicaid) with a household income under 100 percent of the poverty level, and you didn’t enroll in coverage while waiting for the exchange to determine your eligibility for subsidies in the exchange. Once the determination is made, you have access to a special enrollment period (this was clarified in the 2018 Benefit and Payment Parameters, page 247)

• You applied for Medicaid or CHIP during open enrollment, and although you were deemed ineligible, the determination wasn’t made until after open enrollment ended. Medicaid and CHIP enrollment continue year-round, but exchange enrollees who are applying for subsidized qualified health plans (QHPs) must first be screened to ensure that they aren’t eligible for Medicaid or CHIP.Once the state Medicaid/CHIP agency has determined that an applicant is ineligible, the exchange can enroll the applicant in a subsidized QHP. But if the ineligibility determination for Medicaid/CHIP isn’t made until after open enrollment ends (despite the fact that the applicant initiated the process during open enrollment), the exchange can grant a special enrollment period during which the applicant can select a QHP and finish the enrollment process.This SEP applies regardless of whether the initial application for Medicaid/CHIP was initiated through the exchange or directly through the state’s Medicaid office, as long as it was submitted during the annual open enrollment period. But if you’re applying during a special enrollment period, you must apply through the marketplace during your special enrollment period (as opposed to directly through your state’s Medicaid office), in order to continue to have extra time to enroll if your application is subsequently routed to Medicaid and you’re found ineligible for Medicaid after the SEP window has closed (see question 16 in this FAQ series).

Contract violations

The QHP in which you’re enrolled “substantially violated a material provision of its contract” with you. “Substantial violations” have to be investigated, and there’s an official process for this.

It’s important to note that things like formulary changes and network changes can happen mid-year and do not constitute substantial violations. But if you think that your health plan has substantially violated its contract, you can contact the exchange and/or the state department of insurance for instructions on how to proceed.

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.