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).

And DC’s exchange has granted a 60-day special enrollment period in early 2019, for people who didn’t know about the District’s new individual mandate penalty (the dates of the special enrollment period depend on the date the individual contacts the exchange or files a tax return, so they’re different for each person).

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.

Some residents in Alaska, Florida, and Georgia have extra time to enroll in plans for 2019

As a result of an earthquake and a hurricane, residents in some areas of Alaska, Florida, and Georgia have (or had) additional time to enroll in coverage for 2019.

The special enrollment period applies to people in areas declared eligible for FEMA’s “individual assistance” or “public assistance,” and it continues for 60 days after the end of the incident period, as declared by FEMA. But for Florida and Georgia residents affected by Hurricane Michael in October 2018, CMS granted another 60-day special enrollment period after the first one ended. So the deadline on the enrollment period varies depending on where you are and when your area was affected by a FEMA-declared disaster.

  • Georgia: A wide area of southwestern and central Georgia. Special enrollment period continues until February 20, 2019 (it was originally December 22, 2018, but the additional guidance that CMS issued in December gave 60 extra days).
  • Florida: There are 18 counties in the Florida panhandle where residents have until February 16, 2019 to enroll in a plan for 2019 (the original deadline was December 18, but CMS granted another 60-day special enrollment period in December 2018).
  • Alaska: People who were living in the Municipality of Anchorage, Kenai Peninsula, and Matanuska-Susitna Boroughs as of November 30 (when the earthquake occurred) had until January 29 to enroll in a health plan for 2019.

In all cases, affected residents have to call the exchange and explain that they were unable to enroll during open enrollment (or by the end of the original special enrollment period, for affected residents in Florida and Georgia) as a result of the FEMA-declared disaster.

Regardless of where you live, if you believe that you experienced an exceptional circumstance that prevented you from enrolling during open enrollment, 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 cover illustration

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 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

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