Key takeaways
- Exceptional circumstances – personal or widespread – can trigger an SEP.
- Domestic violence or spousal abandonment
- Enrollment errors or delays
- Contract violations (changes to the provider network or drug formulary are NOT considered contract violations)
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 plan through the exchange after open enrollment has ended for the year. These are all case-by-case situations, and they all apply on-exchange, although off-exchange carriers can allow for enrollment flexibility for these situations too.
Exceptional circumstances
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.
[For example, Hurricane Dorian damaged a broad swath of the southeastern US seaboard in September 2019. But since that was not during the open enrollment period, 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.]
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.
In cases of serious natural disasters, the exchanges are likely to issue blanket extensions. This was the case in several states for 2018 coverage following the 2017 hurricane season that caused significant damage along the Gulf coast. HHS announced that there would be a special enrollment period through December 31, 2017 (and later extended through March 31, 2018) for anyone living in areas that FEMA deemed eligible for public assistance or individual assistance following Hurricanes Irma, Maria, Nate, and Harvey.
But in 2018, CMS issued updated guidance on how the special enrollment period would work in states that use HealthCare.gov. Instead of blanket extensions with uniform end dates, they now offer a 60-day special enrollment period that starts when the FEMA-declared disaster incident ends. So residents in different areas have different deadlines for their special enrollment period, and the incident must have ended within 60 days prior to the end of open enrollment (or another special enrollment period for which the person was eligible) in order for the SEP to apply.
As was the case in prior years, the special enrollment period continues to apply to people living in areas deemed eligible for public assistance or individual assistance, and the applicant has to attest that the emergency or disaster affected them and 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.
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.
