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 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.

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.

For example, Minnesota’s exchange used the exceptional circumstances provision to issue a week-long special enrollment period at the end of the open enrollment period for 2017 coverage, in order to allow Minnesota residents to take advantage of a newly-enacted state premium rebate (the legislation for the rebate was signed just a few days before the end of open enrollment).

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.

Residents who already qualified for SEPs in areas impacted by Hurricane Dorian have an extension

A broad swath of the southeastern U.S. seaboard was affected by Hurricane Dorian in September 2019. CMS subsequently announced that their disaster area special enrollment period rules would apply to people in areas declared eligible for FEMA’s “individual assistance” or “public assistance.”

But since the hurricane struck outside of the normal open enrollment period, the FEMA-related SEPs only apply to people who already qualified for a SEP due to some other factor, and were unable to enroll during their original SEP due to the hurricane. In other words, there is not a SEP available to most residents affected by Dorian, since most would not have already been eligible for a SEP prior to the hurricane.

There are areas in North Carolina, Georgia, South Carolina, Florida, Puerto Rico, and the Virgin Islands where FEMA’s public assistance is available as a result of Dorian. People in these areas who already had an ongoing SEP (triggered by a different qualifying event) when the hurricane hit, and who were unable to complete their enrollment during their SEP due to the hurricane, can contact the exchange to request an additional SEP triggered by the hurricane.

[There are no health insurance exchanges or ACA-compliant health plans in the U.S. territories, but people who lived in impacted areas in Puerto Rico or the Virgin Islands during the storm, and who have subsequently moved to the U.S. mainland, are eligible for the extended SEP in their new location; people in this situation would also independently qualify for a SEP due to a permanent move.]

In all cases, affected residents have to call the exchange and explain that they were eligible for a special enrollment period but were unable to enroll during it as a result of the FEMA-declared disaster (all four states affected by Dorian used HealthCare.gov as their exchange). Their special enrollment period extension continues for 60 days after the end of the FEMA-declared disaster, which will overlap with the November 1 start of open enrollment in the fall of 2019.

Regardless of where you live, if you believe that you experienced an exceptional circumstance that prevented you from enrolling during a recent special enrollment period for which you were eligible (or during open enrollment, if you experience exceptional circumstances during that time period), reach out to the exchange as soon as possible to make your case and request a special enrollment period. The exchange will consider the circumstances and make a decision about your eligibility for a special enrollment period on a case-by-case basis.

(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.

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Special Enrollment Guide

Table of Contents

Why a guide to 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 an SEP
12 An SEP for your growing family
13 Exceptional circumstances for special enrollment
14 An SEP if you have a QSEHRA or ICHRA

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