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Exceptional circumstances for special enrollment

When 'life happens' ... and unusual situations make it impossible for you to enroll on time ... you can expect enrollment flexibility

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

special enrollment period for birth of a child

The COVID SEP ended in most states. The American Rescue Plan is still making premiums more affordable.

Soon after taking office, the Biden administration created a special enrollment period in the 36 states that used HealthCare.gov for 2021 coverage, 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.

The COVID special enrollment period applied in all of the states that use HealthCare.gov, but all of the fully state-run exchanges either followed suit, or had already announced COVID-related special enrollment periods before HealthCare.gov’s was announced.

The COVID-related enrollment window has ended in most of the state-run exchanges, but it continues in DC through the end of the District’s pandemic emergency period, for uninsured residents. And New York’s exchange has extended open enrollment for 2022 coverage through the end of the federal COVID public health emergency period.

Open enrollment for 2022 coverage has ended in most states, although open enrollment is still ongoing in New York and Maryland as of February 2022. And Colorado, which has a state-run exchange, is offering a special enrollment period for uninsured residents, running through March 16, 2022, due to COVID, as well as the Marshall Fire.

Although the COVID-specific special enrollment period for HealthCare.gov ended in August 2021, it’s important to note that because COVID is an ongoing federally-declared public health emergency, a person who was unable to enroll in coverage during open enrollment because they were affected COVID is eligible for a special enrollment period to complete their application (note that this is not a blanket special enrollment period; people do have to attest that they were directly affected by COVID — which can include being a caretaker for someone with COVID — in order to qualify for a special enrollment period). This is applicable in states that use HealthCare.gov, although state-run exchanges can set their own rules for how this works.

Note that the ongoing public health emergency for COVID was last extended in January 2022. Each extension lasts for 90 days, so the public health emergency period will continue through at least mid-April 2022. Whether it’s renewed again at that point will depend on the status of the pandemic at that point. The COVID-related SEP guidance for HealthCare.gov remains in place as long as the public health emergency declaration is in effect.

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, Colorado is offering a special enrollment period for people affected by the Marshall Fire and the Omicron surge in the COVID pandemic.

If exceptional circumstances occur during 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 guidance on SEPs when FEMA declares a disaster

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 or a FEMA-declared disaster 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.

Several FEMA-declared disasters occurred during the open enrollment period for 2022 health coverage, providing an extended enrollment opportunity for affected residents. But all of those extended enrollment windows had ended by late February, 2022.

(Note that these specific rules only apply in states that use HealthCare.gov. States that run their own exchanges can set their own rules; Colorado’s special enrollment period through March 16 is an example of this. Another example is Kentucky, which experienced significant FEMA-declared disasters in December 2021 — but Kentucky’s state-run marketplace also used an extended open enrollment window)

Incident period outside of OEP or other SEP does not result in a new SEP (Hurricane Ida example)

FEMA-declared disasters that happen during open enrollment (or a person’s special enrollment period triggered by a separate qualifying event) will result in an extended enrollment opportunity. But a disaster that happens outside of a normal enrollment window will not trigger any sort of widespread special enrollment period.

To give an example of how this works, consider Hurricane 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 were 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.

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. These windows had all ended by mid-October, however (for example, in Nebraska, Missouri, and Michigan, and in Florida for Tropical Storm Elsa and the Surfside building collapse, and Tropical Storm Fred).

There were additional FEMA-declared disasters and emergencies between August 15 and October 31 (ie, after the COVID-related enrollment window, but before open enrollment) in various states that use HealthCare.gov. In those states, a person affected by the disaster or emergency would have only qualified 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 was the case, for example, in Louisiana due to Hurricane Ida. Let’s say you’re in Louisiana and you got married on July 2, 2021, 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 gave you an extra 60 days after the disaster incident period ended, during which you could 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 did take actions to ensure access to health care for people affected by the storm, but a special enrollment period for marketplace coverage was only 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 have been 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 have been the case in 2021 for people in various parts of several states (North Carolina, Louisiana, Mississippi, and Tennessee).

Where the disaster/emergency-related SEP applies

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. Colorado’s special enrollment period in early 2022 for people affected by the Marshall Fire or the Omicron COVID surge is an example of this.

(If you’re uncertain about your eligibility for a special enrollment period, call (619) 367-6947 to discuss your situation with a licensed insurance professional.)

Does pregnancy trigger a special enrollment period?

In most states, no, pregnancy does not trigger a special enrollment period. HHS considered that possibility in the early days of ACA implementation, but clarified in 2015 that they had opted not to include pregnancy as a qualifying event (the birth of the baby is a qualifying event in every state, but that special enrollment period doesn’t begin until the baby is born, meaning that the new health plan will not cover costs related to the pregnancy).

However, state-run exchanges (there are 18 of them as of 2022) can set their own rules for qualifying events and special enrollment periods. And some state-run exchanges have chosen to allow a special enrollment period triggered by pregnancy, allowing the pregnant person to enroll in health coverage and have better access to prenatal care as well as coverage for labor and delivery costs.

As of 2022, pregnancy is a qualifying event in the following state-run exchanges:

And as of 2024, Colorado will consider pregnancy to be a qualifying event for people who don’t already have coverage.

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% 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.

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Table of Contents

Insider’s Guide to Obamacare’s Special Enrollment Periods
1 Qualifying events and why we need them
2 Who doesn’t need a special enrollment period?
3 Involuntary loss of coverage is a qualifying event
4 How your ‘big move’ can trigger an SEP
5 Divorce, death, or legal separation: SEP is optional
6 A change in subsidy eligibility changes your options
7 Citizenship or lawful immigrant status can deliver coverage
8 An SEP if your employer plan doesn’t measure up
9 Non-calendar-year renewal as a qualifying event
10 Leaving the coverage gap? This SEP’s for you.
11 Proving you deserve a special enrollment period
12 An SEP for your growing family
13 Exceptional circumstances for special enrollment
14 An SEP if you have a QSEHRA or ICHRA
15 An SEP if your income doesn’t exceed 150% of the federal poverty level

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Yve
Yve
2 years ago

Can a new immigrant be enrolled in Part B anytime of the year after age 65 since he/she can only apply/register once in the US? Are there any exemption for a situation like this?

Louise Norris
Louise Norris
2 years ago
Reply to  Yve

New immigrants can only enroll in Medicare after they’ve been in the US for five years. Once they reach five years of continuous legal permanent residency, they’ll qualify for an initial enrollment period, during which they can sign up for Medicare Parts A and B, as well as Medigap and/or Part D (this window can take place at any time of the year, since it depends on the date that the person became a legal permanent resident). Assuming they don’t have a work history in the US, they’ll have to pay a premium for Part A (currently up to $458/month as of 2020). Everyone pays a premium for Part B, which is currently $144.60/month.
An immigrant who doesn’t enroll during their initial enrollment period would be limited to enrolling during the annual general enrollment period (January – March), and would be subject to a late enrollment penalty.
You can see more information about immigrants and Medicare here: https://www.medicareresources.org/faqs/can-recent-immigrants-to-the-united-states-get-health-coverage-if-theyre-over-65/

Yve
Yve
2 years ago
Reply to  Louise Norris

Thanks Louise. I should have written ” immigrant married to an American citizen”. Does this make any difference?

Blanca Mesa
2 years ago

What about states like Florida that don’t run their own marketplaces, but depend on federal marketplace. What do they have to do to create a Special Enrollment Period for COVID19?

Steve Anderson
Steve Anderson
2 years ago
Reply to  Blanca Mesa
Dorothy J DeCuir
Dorothy J DeCuir
1 year ago

My last day of work was June 12, 2020, I am receiving 13 weeks of salary continuation, after the 13 weeks I will be eligible for COBRA. Can I change my medical coverage at that time as I am currently in a high deductible and will not be contributing to my HSA for the entire year? I am told neither loosing my job or ending salary continuation is a Life Event, please help me to understand my options.

Louise Norris
Louise Norris
1 year ago

Is your employer structuring it so that you’re essentially considered employed, with your normal health insurance coverage, for 13 weeks after June 12? And then your health coverage would end at that point unless you elect COBRA? If so, the termination of the health plan would count as a life event (loss of coverage). This is true even if COBRA is available. Here’s more about how that works: https://www.healthinsurance.org/faqs/im-leaving-my-job-and-my-insurance-on-june-30-do-i-qualify-for-open-enrollment-on-july-1-or-do-i-have-to-take-cobra/
Your loss of coverage life event will allow you the option to switch to an individual market plan, and you’ll have your choice from among all of the plans available in your area (on-exchange or outside the exchange, but subsidies are only available in the exchange).
If you were referring to switching to a different plan offered by your employer (via COBRA), that would not be an option. COBRA lets you keep your current plan, but doesn’t give you the choice to switch to a different plan when you transition to COBRA.
One other point… if you do keep your current HSA-qualified plan (or pick a different HSA-qualified plan in the individual market), you can continue to contribute to your HSA on your own for the rest of the year. You can open a different HSA or continue to use the account you employer established for you. There’s no requirement that you be employed in order to make HSA contributions.

SCL
SCL
11 months ago

Abandonment of spouse??? When he has his own apartment and as not my spouse at all period. But in a disparate crises like just getting out of a jail. And only a date person his apt was for by a non profit agency. But really for profit. Just like Government set up agencies or alleged programs.. both serve temporary not a permanent way of life. Kids…

Last edited 11 months ago by SCL
Louise Norris
Editor
11 months ago
Reply to  SCL

I’m sorry if you’re going through challenging circumstances. As far as health insurance subsidies go, you can select “unmarried” when you’re enrolling through the marketplace if you’re married but can’t locate your spouse. Here’s more about this: https://www.healthcare.gov/glossary/spousal-abandonment/

J Stark
J Stark
24 days ago

What happens in this situation: we have a special 60 day enrollment period and are allowed to change plans to another carrier, but due to the fact that the escalation team has to manually process the change, we have been delayed in being able to select and finalize our new plan choice. We would have switched plans much earlier, but now it is well into the next month. Meanwhile, we have had ongoing covered medical expenses last month and this month.

If we end up changing to another carrier, and our choice is allowed to be retroactive to the beginning of this month, what can we expect to happen with the claims that have already been processed by the current carrier? If we change to another carrier and it is retroactive to the first of the month, would the claims from earlier in the month be transferred to be reprocessed by the new carrier?

I understand that we would lose accumulated deductible and out of plan totals from prior months if we go to another carrier. But what about pre-authorizations and their effect on any reprocessed claims? Some of the care currently being received was pre-authorized by the current carrier. Since we could not go back in time and get pre-authorizations for care already received, would the new carrier be able to deny those claims, in the event that the way this would be handled would involve reprocessing claims back to the start of the month? Or is this sort of situation, where coverage is retroactive due to delays by the Exchange handled in some other way than by reprocessing existing claims?

Louise Norris
Editor
19 days ago
Reply to  J Stark

This sounds like a complicated scenario. If you’ve been using a broker, you’ll definitely want to reach out to them so that they can contact the insurers and the marketplace and get everything sorted out for you.

If your coverage ends up being retroactive to the first of the month, yes, the claims should get reprocessed by the new insurer. I don’t think there’s any requirement that insurers have to honor another insurer’s prior authorizations, but they certainly could. The marketplace likely wouldn’t get involved beyond sorting out the effective date and transmitting the coverage info to the health plan. But your state department of insurance could get involved if you’re having trouble getting everything sorted out. All of the plans sold in the marketplace are regulated by the state department of insurance, so they could potentially be a good resource for you.

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