Find a plan.

Involuntary loss of coverage is a qualifying event

If you’ve lost or are losing your coverage, a special enrollment period offers you time to enroll in a new health plan with no coverage gap

Involuntary loss of coverage is a qualifying event that triggers a special enrollment period. If you lose your plan, you’ll have a chance to enroll in a new health insurance plan, either on or off the exchange in your state. Here’s how it works:

American Rescue Plan zero-dollar Silver premiums

A major provision of the American Rescue Plan ensures that most Americans who receive at least one week of unemployment compensation at any time in 2021 will be able to buy a Silver health plan with $0 premiums.

The coverage you’re losing has to be considered minimum essential coverage. So if, for example, your short-term plan is ending, that doesn’t count as loss of coverage, since a short-term plan is not considered minimum essential coverage.

(An exception to this rule has to do with loss of pregnancy-related Medicaid coverage, CHIP unborn child, and Medically Needy Medicaid. These are not considered minimum essential coverage, but their termination does trigger a special enrollment period; in 2018, HHS updated the rules to also allow a pregnant woman with only CHIP coverage for her unborn child — but technically no coverage for herself — to qualify for a loss of coverage SEP for herself when the unborn child CHIP coverage ends. These exceptions were clarified in rules that HHS published in 2019.)

(Another note: Although this guide applies to special enrollment periods in the individual market, it’s worth noting that the termination of a short-term plan does trigger a special enrollment period for employer-sponsored coverage (see page 51 here). So if you have access to an employer’s plan and your short-term plan is ending, you’ll be able to enroll in the employer’s plan at that point.)

It’s important to clarify that plans can be considered minimum essential coverage even if they’re not compliant with the ACA. Grandmothered and grandfathered plans count as minimum essential coverage, but do not have to be ACA-compliant. If those plans terminate, the insured has access to a special enrollment period.

Loss of coverage due to rescission does not count as a qualifying event. Rescission is relatively rare now that the ACA has been implemented, but the law does still allow for rescission in the event of fraud or intentional misrepresentation on the part of the insured. (Post-claims underwriting and rescission are still used by short-term health insurance plans, but again, the termination of a short-term plan — for any reason — does not trigger a SEP in the individual market; note that Idaho’s enhanced short-term plans do allow enrollees who have had coverage for at least 11 months to transition to the same carrier’s ACA-compliant plans when their short-term coverage is ending.)

But other than rescission, “involuntary” loss of coverage just means that you didn’t cancel the plan yourself, or lose your coverage because you stopped paying premiums.

what to do if your lose your employer sponsored health insurance

If you lost your employer-sponsored health insurance in 2021, you’ve got options that include subsidized individual-market coverage.

Most non-elderly adults have coverage through an employer-sponsored plan. If they leave their employer – voluntarily or involuntarily – and lose access to their employer-sponsored health insurance as a result, that’s considered involuntary loss of coverage.

So if you choose to leave your job and as a result lose your health insurance, you’ve got access to a special enrollment period to get a new plan in the individual market.

Do I qualify for a special enrollment period even if I have an option to election COBRA?

Yes. The special enrollment period applies even if you have the option to continue your employer-sponsored plan under COBRA. You can choose to elect COBRA, or you can use your special enrollment period to pick a new plan in the individual market. Your special open enrollment begins 60 days before your employer-sponsored policy ends, and continues for another 60 days after the plan would have ended, even if you had an option to extend your coverage with COBRA.

In the early days of ACA implementation, electing COBRA essentially waived the remainder of the person’s special enrollment period. But HHS changed this in late 2016, when they realized that some people were electing COBRA very soon after leaving their jobs (perhaps even during their exit interviews), without a good understanding of what their options are. So the new rules allow people to have their full special enrollment period (including 60 days after the date their coverage would have ended if they hadn’t elected COBRA) regardless of whether they elect COBRA or not.

This is codified in 45 CFR 155.420(e), which clarifies that the loss of coverage special enrollment period for individual market plans applies in various situations that pertain to special enrollment periods in the group insurance market (26 CFR 54.9801-6), including Section (a)(3)(i), which notes that the special enrollment period is available regardless of whether the person elects COBRA.

You’ve also got 60 days to decide whether you want to elect COBRA, with coverage retroactive to coincide with the date your plan would have ended. Between the two windows, you have plenty of time to decide what coverage will work best for you. If you sign up for a plan in the individual market after your employer-sponsored plan ends, your first available effective date will be the first of the following month, so you will have a gap in coverage if you don’t sign up for your new plan before your employer-sponsored plan ends. However, the retroactive availability of COBRA helps to mitigate this, as you could potentially sign up for COBRA during the gap month if you needed to.

When comparing COBRA with a plan in the individual market, be sure to factor in premium tax credits and cost-sharing subsidies if you qualify for them. Your special enrollment period for individual market coverage applies both on and off the exchange, but if you’re eligible for subsidies, you’ll need to get your plan through the exchange.

If you elect to take COBRA and later decide (after your special enrollment period ends) that you’d rather have an individual plan, you’ll have to wait until the next regular open enrollment, unless you have another qualifying event. But exhausting COBRA does trigger a special open enrollment window, because it counts as loss of other coverage.

HHS has also issued new regulations clarifying that the termination of employer or government subsidies for COBRA premiums will also trigger a special enrollment period during which the person can switch to an individual market plan. This became a pressing issue during the COVID pandemic, when many employers paid at least a few months of COBRA premiums for employees, and the federal government provided a full COBRA subsidy through September 30, 2021, for people who involuntarily lost their jobs or had their hours reduced.

For someone in that situation, the COBRA coverage might become unaffordable after the subsidy ends, but without a special enrollment period they would not have had an option to switch to a marketplace plan at that point and potentially start receiving premium subsidies. The new rule provides that flexibility.


Plans that terminate on December 31

If your health plan terminates at the end of the year, you get a special enrollment period that continues for the first 60 days of the new year.

Insurers in numerous states left the exchanges at the end of 2017 or shrank their coverage areas, and the same thing happened at the end of 2016. But that trend began to reverse in 2019, with insurers joining the exchanges in many states. That trend continued for 2020, for 2021, and for 2022. (Even in those years, there were still some year-end plan terminations, including New Mexico Health Connections and Virginia Premier exiting their respective exchanges at the end of 2020. And some. And some enrollees in Washington’s exchange experienced plan terminations at the end of 2021, with Providence exiting the exchange and Premera is shrinking its coverage area.)

For 2023, it appears that the trend of insurer expansions may be reversing once again. Oscar is leaving the exchanges in Colorado and Arkansas, and Bright Health is leaving the exchanges in six states.

If your insurer is no longer offering plans in the exchange in your area, you’re eligible for a special enrollment period. This is true even if you have an on-exchange plan and the exchange maps you to a replacement plan from another insurer when you didn’t select a plan during open enrollment. CMS confirmed in October 2017 that people whose plans are discontinued are eligible for the special enrollment period, despite the fact that the exchange would automatically match these consumers to a new plan if they didn’t pick one themselves (this applies to HealthCare.gov. Most of the state-run exchanges follow a similar protocol, but some do not allow a special enrollment period after the exchange-selected plan takes effect, making it particularly important for people to pick their own plan prior to the end of the year.).

CMS confirmed that the special enrollment period applies in cases where an insurer exits the market in a particular area (on or off-exchange, or both), but it also applies in situations where an insurer replaces all of its PPO plans with HMOs, for example. But more minor adjustments, like changes to the deductible or copay, do not result in a special enrollment period.

(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.)

The special enrollment period also applies if your off-exchange insurer exits the individual market at the end of the year, or shrinks its coverage area and no longer offers plans where you live.

Death, divorce, or legal separation

HHS had originally intended to add a new SEP (for people already enrolled in an exchange plan) effective in 2017 for people who lose a dependent or lose dependent status as a result of a death, divorce, or legal separation, even if they didn’t lose coverage.

But in May 2016, HHS eliminated the requirement that exchanges add this SEP in 2017. Exchanges have the option to do so, but are not required to offer a SEP triggered by death, divorce, or legal separation. Of course, if the death, divorce, or legal separation results in loss of coverage, the normal SEP rules for loss of coverage would apply.

For example, a person who is covered as a dependent on an employer-sponsored plan would lose access to the plan if the employee were to die. Even if 36 months of COBRA were to be available to that person, he or she would also have access to a SEP in the individual market, triggered by loss of coverage. But on the other hand, an enrollee who loses a family member does not necessarily have access to a SEP at that point, unless one of the other qualifying events applies.

Aging off a parent’s plan

Under the ACA, young adults can remain on a parent’s health insurance plan through age 26. The coverage can terminate at the end of the month the person turns 26, but some plans allow the person to remain covered through the end of the year. Either way, the loss of coverage is a qualifying event that allows the young person a special enrollment period during which they can select a new plan.

Special enrollment period details

The special enrollment period triggered by loss of coverage begins 60 days before your existing plan’s termination date, so it’s possible to get a new ACA-compliant plan without any gap in coverage (as long as your old plan is ending on the last day of the month; new plans will only take effect on the first of the month after your old plan ends). This is true regardless of whether the health plan that’s ending is an individual plan or an employer-sponsored plan.

You also have 60 days after your plan ends during which you can select a new ACA-compliant plan.

If you enroll before the date your old plan ends, the effective date of the new plan will be the first of the month following the loss of coverage, regardless of the date you enroll. So for example, if your plan is ending July 31, you can enroll in June or July and your new plan will be effective August 1 (if your plan ends mid-month, however, the new plan would still start the first of the following month, leaving you with a gap in coverage; a short-term plan might be a good option to cover those interim days).

But if you enroll in the 60 days after your plan ends, the exchange (or carrier, if you’re enrolling outside the exchange) can either allow a first-of-the-following-month effective date regardless of the date you enroll, or they can use their normal enrollment deadline, which can either be the 15th of the month or the end of the month, in order to have coverage effective the first of the following month.

As of 2022, HealthCare.gov no longer uses the 15th-of-the-month deadline; applications submitted during a special enrollment period will have coverage effective the first of the following month, regardless of the date the application is submitted. But that would still result in a gap in coverage if you enroll after your plan has ended, since the new plan will not have a retroactive effective date.

When you’re enrolling in a new marketplace plan due to loss of other coverage, the application will ask you when your coverage is ending. It’s important to note the last day that the coverage will be in force, not the first day you’ll be without coverage. So for example, if your plan is ending on June 30, you would put your loss of coverage date as June 30, rather than July 1. If you indicate July 1, the system will push your new effective date out to August 1, since that’s the first of the following month.


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.

Find affordable health plans.

Helping millions of Americans since 1994.

(Step 1 of 2)

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

Related articles

0 0 votes
Article Rating
Subscribe
Notify of
guest
51 Comments
Oldest
Newest Most Voted
Inline Feedbacks
View all comments
Claudia Haworth
Claudia Haworth
2 years ago

Am I eligible for a SEP in the individual market if I turned 26 and am no longer covered under my parent’s health plan?

Louise Norris
Louise Norris
2 years ago

Yes. Losing coverage under your parent’s plan is a qualifying event. You have 60 days from the date your plan ended to sign up for a new policy in the exchange or directly through an insurer (premium subsidies are only available in the exchange). Here’s an FAQ that might be useful: https://www.healthinsurance.org/faqs/the-aca-allowed-young-adults-to-remain-on-their-parents-health-plans-until-age-26-now-that-its-2014-has-anything-changed/

Jeannie
Jeannie
2 years ago

I currently have insurance through my job, but I will be leaving my job in December. My husbands enrollment period is in November. When open enrollment comes around for him can I go back on his insurance?

Louise Norris
Louise Norris
2 years ago
Reply to  Jeannie

Yes, but you might not be able to leave your employer’s plan until you leave your job. Once you’re enrolled in a plan through your employer, you generally cannot disenroll until your plan’s open enrollment window (with the disenrollment effective at the start of the next plan year) or until you leave the job or otherwise lose eligibility (eg, a reduction in hours, etc.). To address the COVID-19 pandemic, the IRS is giving employers the option to offer some flexibility on this, but it would depend on whether your employer opts to allow that flexibility and whether the pandemic is still ongoing at that point: https://www.healthinsurance.org/obamacare/state-and-federal-efforts-to-improve-access-to-covid-19-testing-treatment/#FSA
If your husband’s plan year starts on January 1, the timing should be fine if your existing coverage can run through the end of December and your coverage under his plan starts in January. But if his plan renews in December (following an open enrollment period in November), you might have one month of double coverage.

Mary Ann Kingston
Mary Ann Kingston
2 years ago

I was furloughed in March and then declined offer to return to my job in May but my employer-sponsored health insurance has not been discontinued — apparently my employer has not notified the insurer that I am not working. I understand that if my employer notifies the insurer now, I could get insurance under COBRA or Special Enrollment Period (SEP) rules for qualifying life event. However, could my employer terminate my insurance retroactively and thereby cause me to be outside the 60-day period to qualify under the SEP rules? Should I alert my employer that the insurer has not been notified that the employment has ended?

Louise Norris
Louise Norris
2 years ago

Yes, you should alert your employer that the insurer has not been notified of your termination of employment. But no, the employer cannot retroactively terminate your health insurance, as explained here: https://www.theabdteam.com/blog/terminated-employees-not-terminated-coverage-2/
Your special enrollment period during which you can select a plan in the individual market would end 60 days after your employer-sponsored plan ends. But the COBRA election period has been extended to address the COVID-19 situation: https://www.healthinsurance.org/obamacare/state-and-federal-efforts-to-improve-access-to-covid-19-testing-treatment/#COBRA

Winston DiNicola
Winston DiNicola
2 years ago

I currently have COBRA coverage which will end on Sep 30th, 1 month prior to the start of the Open Enrollment Period of Nov 1st. I have a two part question:
1. Am I eligible for a SEP to enroll in an individual plan in my state of NC?
2. I will be turning 65 the following July and will be enrolling in Medicare. Does this qualify for SEP consideration for me to get off of the individual insurance plan while keeping coverage for my wife and daughter?

Louise Norris
Louise Norris
2 years ago

1. Yes, you’ll be able to enroll in an individual market plan when your COBRA coverage ends. If you enroll in the 60 days prior to your loss of coverage, your new plan will take effect October 1, so you won’t have a gap in coverage. You’ll also have a chance to enroll in the 60 days after 9/30, but then you’d have a gap of at least 1 month between your COBRA plan ending and your new plan starting.
2. Yes, you’ll be able to transition to Medicare next summer. Your wife and daughter will be able to remain on the marketplace plan (keep a close eye on the termination notices you get from the marketplace after you initiate your own coverage cancellation, just to make sure they don’t accidentally cancel the whole policy). Here’s more about the transition from an individual market plan to Medicare: https://www.medicareresources.org/medicare-eligibility-and-enrollment/moving-from-obamacare-to-medicare/

Bonnie
Bonnie
2 years ago

My husbands work just let us know that our health insurance deductible is increasing from $4,000 to $10,000, and I’m expecting a baby in 3 months.
Effectively we went from having insurance to not have usable insurance.
Can this possibly qualify for a special enrollment?

Louise Norris
Louise Norris
2 years ago
Reply to  Bonnie

I assume the plan is renewing, and the new deductible will apply to the new plan year? If so, you’ll have a special enrollment period that will allow you to switch to a plan in the individual market instead of keeping your existing plan for the upcoming plan year, even if your current plan doesn’t follow the calendar year: https://www.healthinsurance.org/special-enrollment-guide/non-calendar-year-renewal-as-a-qualifying-event/
I assume also that the deductible you’re describing is for the whole family? Health plans are not allowed to have an individual out-of-pocket maximum in excess of $8,150 this year, or $8,550 next year, unless they’re grandfathered or grandmothered (and that sort of deductible change would make a grandfathered plan lose its grandfathered status).
If your employer’s plan stops providing minimum value and/or no longer meets the affordability guidelines, you would also have a special enrollment period in the individual market, and could potentially qualify for premium subsidies in the individual market. Here’s more about this: https://www.healthinsurance.org/special-enrollment-guide/an-sep-if-your-employer-plan-doesnt-measure-up/
One thing to keep in mind, however, is that a new plan would mean starting over with a new deductible and out-of-pocket maximum, which would again reset at the start of 2021. Depending on how much you’ve already accrued towards your plan’s out-of-pocket limit for this year, that’s something you’ll need to take into consideration.

Bonnie
Bonnie
2 years ago
Reply to  Louise Norris

Thank you Louise for your detailed answer. Your first paragraph is exactly what we were looking for!

Mason
Mason
2 years ago

I had a full-time temporary teaching position and was offered health insurance. At the end of the summer my health insurance was terminated because the teaching position wasn’t available. Do i qualify for special enrollment?

Louise Norris
Louise Norris
2 years ago
Reply to  Mason

Yes. A plan offered by an employer is considered minimum essential coverage, and the termination of that coverage is considered a qualifying event that will allow you to enroll in an individual market plan (on-exchange or outside the exchange, but subsidies are only available in the exchange).

James
James
1 year ago

My wife will soon be starting a new job, but the health insurance is terrible. She would prefer to stay on COBRA with our kids until it expires 3/31/22. I know that by staying on COBRA she is barred from electing coverage through her employer until the next open enrollment period. But can she still be added to my health insurance through my employer once COBRA expires? Thanks.

Louise Norris
Editor
1 year ago
Reply to  James

When her COBRA expires, she will qualify for a special enrollment period for her own employer’s health plan and your employer’s health plan. She will not have to wait until her employer’s annual open enrollment period, since she’ll be experiencing an involuntary loss of coverage when she exhausts her COBRA.

Details are in 29 CFR 2590.701-6 (a)(3)(iii) https://www.law.cornell.edu/cfr/text/29/2590.701-6

Last edited 1 year ago by Louise Norris
Ashton
Ashton
1 year ago

I lost my job on 08/02/21 and my employer offered to pay for COBRA till end of November 11/30/21.
My wife declined insurance from her employer last year since she was under my plan.
My understanding is that we can enroll in my wife’s company plan under SEP option, I am confused about the dates of enrollment though.
Do we need to enroll now considering job loss date 08/02/21 as a qualifying event, or we can enroll 60 days prior to coverage loss/end date i.e. 11/30/21. In summary my question is

  1. what is a qualifying event, loss of job or end of health coverage?
Louise Norris
Editor
1 year ago
Reply to  Ashton

The loss of coverage is always the qualifying event. So whatever date your coverage is ending will be the date of the qualifying event. Your wife’s employer will likely ask for proof of the coverage loss, so you’ll provide them with a copy of the letter from your current insurance, showing the termination date will be 11/30/21. You should be able to enroll in her plan with a start date of 12/1.

Ashton
Ashton
1 year ago
Reply to  Louise Norris

Thank you, Louise.
So can I enroll 30 days prior to coverage expiration which is Nov 1st?

Louise Norris
Editor
1 year ago
Reply to  Ashton

Yes, that should be the case. Your wife will want to check with her employer to make sure that she complies with any documentation requirements they have (to prove the impending coverage loss on November 30). But in general, she should be able to enroll both of you in her plan in November, with coverage effective December 1.

Eddie Perez
Eddie Perez
1 year ago

I have two full time jobs currently and have insurance through one of them. I will be going part time at the job I have insurance through, and therefore will be losing my medical benefits. Do I qualify for a SEP through my other full time job to get medical benefits?

Louise Norris
Editor
1 year ago
Reply to  Eddie Perez

Yes. The loss of your coverage will trigger a special enrollment period during which you’ll be able to sign up for the coverage that’s offered through your other job. They’ll need you to show proof that your current coverage is ending, so be prepared to provide that documentation.

Rose
Rose
1 year ago

If I currently qualify for Medicaid and end up making over the amount allowed, thus lose my coverage, am I able to get insurance through my employer outside of the enrollment period?

Louise Norris
Editor
1 year ago
Reply to  Rose

If you lose your coverage, yes, that would count as a qualifying event. But during the COVID public health emergency, states are not terminating Medicaid coverage unless a person requests the termination or moves out of state. The public health emergency was most recently extended just last month, and CMS has also given states a full 12 months to conduct eligibility redeterminations after the public health emergency period ends (an unknown date, at this point): https://www.healthcaredive.com/news/cms-extends-deadlines-for-medicaid-redeterminations-after-covid-19-public-h/605122/
So for the time being, you shouldn’t lose your Medicaid coverage in the near future due to a change in income. But if and when you do, then yes, that would count as a qualifying event and you’d be able to enroll in your employer’s plan outside of open enrollment, by showing proof of the coverage termination.

Jason
Jason
1 year ago

I’m 19. If my dad drops me from his insurance plan (but he doesn’t cancel the plan, he just drops me) is that a qualifying event?

Louise Norris
Editor
1 year ago
Reply to  Jason

Technically, no. That would not be considered an involuntary loss of coverage, since you could still be covered under the plan but your dad would be choosing to drop you from it. You would have an opportunity to enroll in a new plan during open enrollment, which starts November 1, for coverage effective January 1.

If your dad is insisting on dropping you from his plan, you could try submitting an application through the marketplace with documentation from your previous insurer showing the date that the coverage ended. It’s possible that they might accept it as proof of loss of coverage. Otherwise, you could enroll in a short-term plan (if those are available in your state) to cover you until December 31, with your new marketplace plan (selected during open enrollment) taking effect January 1. Best of luck!

Renata M Garcia
Renata M Garcia
1 year ago

Does me taking off my husband at my OE constitute an involuntary loss of coverage for him and give him the right to get on his plan in the middle of his plan year?

Louise Norris
Editor
1 year ago

It would trigger a special enrollment period for him to enroll in a marketplace plan, since your plan follows a non-calendar-year schedule: https://www.healthinsurance.org/special-enrollment-guide/non-calendar-year-renewal-as-a-qualifying-event/
But that provision doesn’t trigger a special enrollment period for employer-sponsored health coverage. So if he’s wanting to switch to his employer’s plan, he’d need to check with them to see if they’d allow this. Switching from one spouse’s plan to another’s when the enrollment periods don’t align can be challenging: https://khn.org/news/switching-to-a-spouses-plan-can-be-difficult-if-timing-isnt-right/

Danielle Wilmot
Danielle Wilmot
1 year ago

My employer’s insurance period runs Nov. 1 – Oct. 31, rather than aligning with the calendar year (their open enrollment starts today). I’m eligible to re-enroll, but the terms with my employer have changed – they have so far covered 100% of premiums, and will be dropping that to 80% (leaving me responsible for 20%). My husband’s plan would cover both of us 100% (including premiums) and benefits are similar, but open enrollment for his plan is not until November, and coverage would not start until Jan. 1. I’m trying to figure out my best course of action – ideally, I’d like to get on his plan starting Nov. 1, but I’m not sure that “My employer is no longer covering my premiums 100%” qualifies as “involuntary loss of coverage” (allowing me to enroll earlier for his plan on 11/1), nor that “I’m now eligible for my husband’s plan” would be enough to let me drop my employer’s plan as of 1/1 and switch to my husband’s. Is there a way to make this work? Or do I need to enroll in both and just be double-covered for 10 months (Jan-Oct) before I can drop my plan entirely and be only on my husband’s? The other option would be doing COBRA or something for the last 2 months of 2021, which would probably cost more than just paying the 20% premiums on my plan for another year.

Louise Norris
Editor
1 year ago

Unfortunately, there is not a special enrollment period for situations like this that would allow you to switch to your husband’s employer-sponsored plan. And COBRA is unlikely to be available, since you’re still eligible to be covered under the regular plan for active employees (COBRA requires a qualifying event – either termination of employment, or a reduction in hours that makes you ineligible for the plan).

There is, however, a special enrollment period that would allow you to switch to a self-purchased plan in the individual market: https://www.healthinsurance.org/special-enrollment-guide/non-calendar-year-renewal-as-a-qualifying-event/

But you wouldn’t qualify for premium subsidies, since you have an offer of coverage from both your employer and your husband’s employer (assuming that at least one of those offers is considered affordable, which means the employee-only premiums aren’t more than 9.83% of household income in 2021)

So you would be paying full price for a plan purchased in the marketplace for November and December, and then you could enroll in your husband’s employer-sponsored plan with coverage starting in January. Self-purchased plans do not have annual coverage requirements the way employer-sponsored plans do; you’re free to drop your coverage at any time.

Your idea of double coverage might end up being beneficial, depending on how the coordination of benefits works. That would be something to check with both HR departments about, before making a decision. Here’s an overview of model coordination of benefits rules: https://content.naic.org/sites/default/files/inline-files/MDL-120.pdf (but one or both of the plans might have different rules that they use).

One last point… although choosing to drop your employer-sponsored plan is not a qualifying event, people do sometimes make this work. The certificate of coverage from your prior insurance would state the end date for your plan, and your husband’s employer might just accept that without needing anything further. The certificate of coverage statement will likely just indicate that the plan has ended, but not the reason. So although this is not technically a way to qualify for a special enrollment period, some people have success with it.

And although short-term health plans are very much a buyer-beware scenario, they are a possible option for situations like this (ie, where you have to wait to enroll in a group plan, and aren’t eligible for any subsidies to offset the cost of an ACA-compliant plan). Here’s a series of FAQs about how they work (and you can select your state on the drop-down to see specific details about short-term plan rules): https://www.healthinsurance.org/short-term-health-insurance/

Danielle Wilmot
Danielle Wilmot
1 year ago
Reply to  Louise Norris

Thank you!

Ashley
Ashley
11 months ago

My job is requiring “Proof of Loss of Coverage” in order to enroll in their health insurance program. I aged out of my parent’s insurance plan. I do not have “proof” of this because I do not speak with my parents and I do not receive letters from the insurance company? Is there a way to enroll without this “proof”?

Louise Norris
Editor
11 months ago
Reply to  Ashley

Unless you want to wait for your employer’s open enrollment period, you will need to show proof of your qualifying event (in this case, loss of coverage) in order to enroll. And there’s likely a 30-day deadline after your loss of coverage, so this is something you’ll need to do fairly quickly.

But you should be able to reach out to the insurance company that was providing or administering the coverage, and ask them to send you proof that your coverage terminated, which will indicate the last day that it was in force. Then you can provide that document to your employer in order to enroll in the plan they offer.

Rhonda Stanley
Rhonda Stanley
10 months ago

Hello! I was recently informed that the hospital and a number of my current doctors was recently dropped from the Anthem group insurance in my area. My monthly premium is very high. I do not feel it is fair to force an insured person to a smaller pool of choices as a result. Would I be able to get out from underneath this plan and go with something else now that Open Enrollment is over? This seems like it could be a Qualifying Event reason. Thank you!

Louise Norris
Editor
10 months ago
Reply to  Rhonda Stanley

Probably not, unfortunately. This is not a qualifying event for individual market coverage, and it also doesn’t appear in the list of qualifying events that trigger special enrollment periods for group coverage: https://www.law.cornell.edu/cfr/text/29/2590.701-6#a_2

If this is a group plan, you can discuss the issue with your employer and see what they say. But in general, mid-year provider network changes are not a qualifying life event.

Kate
Kate
9 months ago

Good Morning, I have an employee that is covered under her husbands plan. Their child lost CHIPs coverage. I know the child can be added to the husbands plan, but could she drop her husband’s plan and get on our plan with the child. The child’s current doctors are not in network on the husband’s plan. Could that be done as a QLE?

Louise Norris
Editor
9 months ago
Reply to  Kate

I think so, but you’d need to confirm with the HR department and/or the two health plans to be certain. The rules for qualifying events are different in the employer-sponsored market, and are detailed here: https://www.law.cornell.edu/cfr/text/29/2590.701-6

Section (2)(ii) clarifies that both the employee and the dependent are eligible for a special enrollment period when the dependent loses coverage. There are some conditions that apply, but from what you’re describing, it sounds like those conditions would be met in this case.

Brian Sarkisian
Brian Sarkisian
8 months ago

I recently ran into the situation that your last paragraph spoke about.

Starting in 2022, HealthCare.gov will no longer apply the 15th-of-the-month deadline; applications submitted during a special enrollment period will have coverage effective the first of the following month, regardless of the date the application is submitted. But that would still result in a gap in coverage if you enroll after your plan has ended, since the new plan will not have a retroactive effective date.

I reached out to the Market Place and got different answers on the 15th of month deadline for SEP applications. Two said that a person in
the situation would be fine, and the other two said the person would have to enroll by the 15th.

  1. Can this information be found on Healthcare.gov ( I couldn’t find)
  2. What page of the referenced Federal Register can this be found?
Louise Norris
Editor
8 months ago

Here’s the version of the applicable Notice of Benefit and Payment Parameters that has page numbers: https://www.govinfo.gov/content/pkg/FR-2020-05-14/pdf/2020-10045.pdf You’ll find this provision on page 29207, starting in the middle column about mid-way down the page.

As of today, they have not yet updated the code of federal regulations for this: https://www.ecfr.gov/current/title-45/subtitle-A/subchapter-B/part-155#155.420 (155.420(b)) But I would expect that to be updated soon.

Yvonne Deemer
Yvonne Deemer
8 months ago

Is it considered involuntary loss of coverage if the premium of the current plan increased so that it was unattainable to the recipient? We offer health coverage as her current employer, however, her old insurance became impossible for her to afford. She missed our open enrollment, but had to drop her coverage due to financial reasons.

Louise Norris
Editor
8 months ago
Reply to  Yvonne Deemer

It does count as a qualifying event for individual/family (self-purchased) coverage if the employer-sponsored plan becomes unaffordable or stops providing minimum value (both of those have official definitions; it’s not subjective): https://www.healthinsurance.org/special-enrollment-guide/an-sep-if-your-employer-plan-doesnt-measure-up/
However, I’m not aware of that being a qualifying event that will allow a person to enroll in employer-sponsored coverage. The rules for that are different, and are outlined here: https://www.law.cornell.edu/cfr/text/29/2590.701-6

Javier
Javier
8 months ago

I had an individual health insurance plan that ended December 31st and I decided to get a better plan to begin January 1st 2022.
My plan is in autopay.

I received the new insurance card with the better plan in the beginning of January however when a few days latter I went to see a Dr I discovered that my policy was terminated Dec 31 2021 in spite of me getting the new insurance cards.

I called customer service and they did not know why that happened, and the next week customer service called me to let me know that my policy was reinstated.

Great. I was able to see the Dr. and get blood work done and get a prescription filled but today January 24 I got a call from my Dr telling me that my member number was again not valid. The same thing again.!!!
I called again customer service and they told me the same, that they did not know what happened and that they would email the individual policies department again.

So now for a second time in January I am uninsured!!!…..is that legal??…what would happen if i now get Covid or if I have to go to the ER for any reason???.the insurance was again cancelled without even notifying me!!

I don’t know what I can do or whom I should contact.

Since January 15 is over I dont even have the possibility of enrolling with another insurer!!!
Will this qualify as loss of coverage so that I could get insurance with another carrier? How do I demonstrate that I was insured and that I was terminated involuntarily?

I really don’t know what I should or can do.

It is really stressful to be uninsured at this moment.

Last edited 8 months ago by Javier
Louise Norris
Editor
8 months ago
Reply to  Javier

I’m sorry you’re having to deal with these glitches – that does indeed sound stressful. This article might provide some helpful information: https://www.healthinsurance.org/faqs/who-can-help-if-i-have-a-problem-with-my-aca-compliant-coverage-or-exchange-enrollment/

Technically, it is considered a qualifying event if your insurer “substantially violated a material provision of its contract:” https://www.healthinsurance.org/special-enrollment-guide/exceptional-circumstances-for-special-enrollment/#violations But I doubt that this situation would qualify as that, since the insurer has said that it’s a glitch/mistake, and it sounds like they’re working to correct it.

Are you enrolled through the marketplace in your state? If so, contacting the marketplace directly might help. And do you have a broker who helped you sign up for your plan? If so, part of the broker’s job is to sort out issues like this. If you don’t have a broker, using one in future years will ensure that you have someone to handle situations like this, and there’s no charge for a broker’s services.

Jessica
Jessica
6 months ago

Am I eligible for SEP?

I lost covered December 31, 2021 when plan ended due to non-renewal from the carrier. I was unaware because payment was set for auto withdrawal and plan would renew in the past. I just discovered this and it is March 2022. Can I apply for SEP in the state of Pennsylvania under event of “Loss of Minimum Essential Coverage”?

Louise Norris
Editor
6 months ago
Reply to  Jessica

There’s only a 60-day window for the SEP due to loss of minimum essential coverage. If your previous plan ended December 31, your SEP would have ended March 1, unfortunately. Assuming that the old plan did notify you of the non-renewal, it’s unlikely that a SEP extension would be granted. But you can certainly reach out to the marketplace in Pennsylvania (Pennie.com) to talk with them about any extenuating circumstances.

Ross
Ross
6 months ago

My wife is losing coverage effective 3/31 through her employer, and moving to a plan with my employer via a special enrollment period. 2 questions:

1. I am planning to send my HR a request to enroll her this Monday or Tuesday (3/21 or 3/22), as soon as we get proof of loss of coverage. I work in the federal government and the HR process can take time. Do I have anything to be concerned about in terms of getting my wife covered effective 4/1?

2. Let’s say my wife gets a new job soon after enrolling in my coverage. Let’s hypothetically say her new job offers her coverage effective 5/1, but she had already enrolled in my employers coverage via special enrollment effective 4/1. Would there be any issues with her hopping on her new employers coverage, in addition to staying on mine?

Thanks in advance. This article is incredibly helpful!

Louise Norris
Editor
6 months ago
Reply to  Ross

Hi Ross,
Just to clarify, this article is specific to special enrollment periods in the individual/family market. The rules are different for employer-sponsored plans, are the details are outlined here: https://www.law.cornell.edu/cfr/text/29/2590.701-6

But in this case, no, there should not be any problem in terms of her coverage starting April 1 under your plan (see (a)(4)(ii) in that statutory language; coverage starts the first of the month following the date of the application/enrollment).

There should also be no problem with her joining her new employer’s plan in addition to staying on yours. But you’ll want to discuss this with both HR departments to understand how the coordination of benefits will work, whether the two plans have overlapping provider networks, how much you’ll pay in total premiums, etc.

Ross
Ross
6 months ago
Reply to  Louise Norris

Thank you so much, this was very helpful!

Alisha
Alisha
6 months ago

Hello,
McFarlane, and I am looking for professional assistance with my Marketplace insurance issues I’m having. 
    I have had coverage through Marketplace since September 2021. I legally changed my last name since enrolling, so on Monday I called healthcare.gov assistance to change my name. They directed me through the application again to report any life changes. One life change that I added is that I’m pregnant. Unfortunately, this addition terminated my insurance plan and automatically applied for medicaid. I know I will not qualify, but now I have a lapse in coverage with a baby coming in six weeks. Anyone that I’ve gotten on the phone through healthcare.gov has just told me I need to wait until Medicaid denies me which could take weeks. In the meantime, I will not be able to go to my required Obstetrician visits without my insurance. Marketplace instructs to not cancel insurance until the medicaid application goes through, but I had no choice as my plan was terminated automatically with the application to medicaid. Now I’m told I cannot re-enroll until November, but I have a baby coming in six weeks! I did not wish to terminate my coverage in the first place, and I have no idea why it happened!

Louise Norris
Editor
6 months ago
Reply to  Alisha

Alisha,
I’m so sorry you’re having to deal with such a stressful situation. When you’ve contacted HealthCare.gov, have you escalated the situation to a supervisor? And if you used a broker when you first enrolled, they will be able to help you with this situation too.

If a marketplace supervisor cannot help you and you do not have a broker, it might help to call your Congressional representative’s office and explain the situation. I have heard from colleagues who say they have seen similar situations resolved quickly when staffers from a member of Congress get involved.

Another issue to keep in mind is that they really need to be reinstating the same policy you’ve had since January 1, rather than starting you over with a new policy as of April 1 (or some other date). You’ve likely had some out-of-pocket expenses already this year, and it would be unfair to make you start over with a new deductible and out-of-pocket maximum. So the solution they need to be working toward would be either reinstating the original policy, or starting a new policy (the same one you had before) and making sure that any out-of-pocket costs you’ve incurred since January are credited to that plan. They will likely make this happen automatically, but you’ll want to check to make sure that everything is done correctly with this.

I wish you all the best, and congratulations on the new little one!

Last edited 6 months ago by Louise Norris
Annie
Annie
30 days ago

Hello, I’m wondering if this situation qualifies for a SEP:

I worked for a school district, and our benefits were on a July 1st to Jun 30th schedule. They cover you over the summer (I was staff, not a teacher) and then you pay the premiums over the school year. I resigned at the end of August this year because I was offered a job that I was not expecting to get. I did not plan on this, it was a surprise to be offered the job, I did not intentionally use the benefits knowing I would leave.

HR retroactively terminated my health insurance from July 1st and offered me a COBRA when I resigned on August 29th. I am trying to go on my husband’s policy, as my new job does not offer insurance. I’m afraid that because my policy officially ended June 30th, which is over 60 days ago now, we will not be allowed to call it a “loss of employer coverage / qualifying life event” because the ‘official’ date the policy ended is too long ago.

Could it still qualify even though they retroactively ended the coverage? I’m fine with paying the COBRA for July and August, but was hoping to go on my spouse’s policy starting in September. Will the new insurance company be able to say this is technically too late even though I didn’t really know until August 29th?

Louise Norris
Editor
29 days ago
Reply to  Annie

Annie,
That’s a really tricky situation. My recommendation would be to speak with your spouse’s HR department and explain the situation. You could show them to notice from your previous employer (which is dated this week) saying that your coverage was being retroactively terminated. Their specific rules will depend on what they’ve spelled out in their summary plan description, in terms of how they handle special enrollment periods. They have to provide at least 30 days (it’s 60 for individual/family plans, and 30 for employer-sponsored plans), but I’m not sure how they’ll handle it in a situation like this, where coverage was retroactively terminated back more than 30 days.

51
0
Would love your thoughts, please comment.x
()
x