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.

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 was 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 ended August 15, 2021.

This window gave uninsured Americans a chance to get coverage, and it was also an excellent opportunity to take advantage of the new premium subsidies made available by the American Rescue Plan (as noted below, people affected by FEMA-declared disasters and emergencies that occurred during the COVID-related special enrollment period could potentially be eligible for an extended enrollment window).

The COVID special enrollment period applied in all of the states that use HealthCare.gov, but all 15 fully state-run exchanges either followed suit, or had already announced COVID-related special enrollment periods before HealthCare.gov’s was announced. The enrollment deadline has already passed in many of those state-run exchanges, but there are several state-run exchanges where enrollment in 2021 plans is still available without a qualifying event after August 15, with the following enrollment deadlines:

• California: Through December 31 for uninsured residents and those switching from off-exchange to on-exchange coverage. California also announced a temporary wildfire-related SEP, for residents in areas where a state of emergency has been declared due to wildfires.
• Connecticut: Through October 31
• DC: Through the end of the pandemic emergency period
• Minnesota: The general COVID-related special enrollment period has ended, but people who have received unemployment compensation in 2021 can still enroll or change to a $0 premium silver plan)
• New Jersey: Through December 31
• New York: Through December 31

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. As noted above, for example, California issued a special enrollment period in August 2021 for people living in areas where a wildfire-related state of emergency has been declared.

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, consider Hurrican Ida, which caused extensive damage along the Gulf coast and in the northeastern United States in 2021. Ida was a devastating storm, but it struck in late August and early September. That was after the COVID-related special enrollment period had ended in most of the affected states, and before the start of the general open enrollment period that begins in November each year. So residents in affected areas only became eligible for a storm-related 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 have been several weather-related or fire-related events in the summer and fall of 2021. These events happened before the annual open enrollment period, but some of them happened during the COVID-related special enrollment period that continued through August 15, 2021 in states that use HealthCare.gov (explained in more detail above).

So there was a potential extension of the special enrollment period for a person who was unable to enroll during the COVID-related enrollment window due to a FEMA-declared disaster or emergency that occurred less than 60 days prior to the end of the COVID-related enrollment period. Some of these windows have already ended (for example, in Nebraska, Missouri and Michigan, and in Florida for Tropical Storm Elsa and the Surfside building collapse), but affected enrollees could still potentially enroll in the following areas:

Potential COVID/American Rescue Plan SEP extension for residents affected by natural disasters:

• Affected counties in Florida — ends October 18 (Tropical Storm Fred, August 2021)

There have been additional FEMA-declared disasters and emergencies since August 15 in various states that use HealthCare.gov. In those states, a person affected by the disaster or emergency will only qualify for a special enrollment period if they were otherwise eligible for their own individual special enrollment period (due to a personal qualifying life event, such as a loss of other coverage, marriage, birth/adoption of a child, etc.).

This would be the case, for example, in Louisiana due to Hurricane Ida. Let’s say you’re in Louisiana and you got married on July 2, creating a 60-day window to add your new spouse to your health plan. You were just about to do that when Hurricane Ida struck, but the hurricane knocked out your power and you weren’t able to complete the enrollment. The disaster declaration gives you an extra 60 days after the disaster incident period ends, during which you can add your new spouse to your health plan.

But although Hurricane Ida was a devastating event in Louisiana and Mississippi, it did not create a widespread special enrollment period. CMS has taken actions to ensure access to health care for people affected by the storm, but a special enrollment period for marketplace coverage would only be available as an extension to an existing special enrollment period triggered by an individual’s qualifying life event. If you didn’t have an ongoing special enrollment period during the Hurricane Ida incident period, you wouldn’t be eligible for a special enrollment period due to the storm.

However, if you had experienced a qualifying event and were thus eligible for a special enrollment period during a FEMA-declared disaster or emergency, you’re potentially eligible for an extension of your special enrollment period if you were unable to enroll due to the disaster. This could be the case in 2021 for people in affected parts of the following states:

Potential SEP extension for people who already qualified for a personal SEP and were affected by a disaster:

• North Carolina — through October 17 (remnants of Tropical Storm Fred)
• Louisiana — through October 28 (Hurricane Ida)
• Mississippi — through October 31 (Hurricane Ida)
• Tennessee — through October 20 (severe storms/flooding)

The disaster/emergency-related special enrollment period on HealthCare.gov 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.

States that run their own exchanges can create their own disaster/emergency-related special enrollment periods. There have been some FEMA-declared disasters in 2021 in states that have their own marketplaces — for example, Hurricane Ida remnants in New Jersey and New York, and the wildfires in California. But all three of those states have extended their COVID/American Rescue Plan enrollment windows through the end of 2021 anyway, and California has added a special enrollment period for people affected by the wildfires.

(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.

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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.