Chapter 1: Special Enrollment Guide

Qualifying events and why we need them

The concept of enrollment periods for health insurance isn't new. Fortunately, neither is the concept of special enrollment periods.

The Insider's Guide to Obamacare's Special EnrollmentBefore the bulk of the Affordable Care Act’s provisions took effect in 2014, health insurance carriers in the individual market accepted applications all year round. But not all of those applications were approved.

Applications from people with significant pre-existing conditions were rejected altogether in all but five states. And even people with relatively minor pre-existing conditions often found that they were only able to get a policy that either excluded their pre-existing conditions or charged them higher premiums as a result of their medical history.

That’s all changed now. Applicants can no longer be rejected or charged a higher premium because of pre-existing conditions; applications don’t even ask questions about medical history anymore.

Why the need for open enrollment

But the trade-off is that enrollment is limited to an annual open enrollment period and special enrollment periods triggered by qualifying events. It’s easy to see why this is necessary: if enrollment were available year-round without any limitations on coverage for pre-existing conditions, adverse selection would be a serious problem.
People would be able to wait to enroll until they were in need of healthcare, and skip paying premiums the rest of the time. (The ACA’s penalty for being uninsured would apply, but even now that it’s fully deployed, the cost of coverage is typically more than the cost of the penalty, and the IRS has few tools available to enforce collection of the penalty.)

In short, it wouldn’t be sustainable to allow year-round enrollment in plans that are guaranteed-issue regardless of medical history.

So when the ACA was written, it included a provision to limit enrollment to an annual open enrollment period. The specifics in terms of the dates and length of open enrollment have changed several times over the last few years, but will eventually settle at November 1 to December 15 each year, with coverage effective January 1 of the coming year. (This schedule will take effect in November 2018, for coverage effective in January 2019.)

Once open enrollment ends for the year, enrollment is closed in the individual market, on and off the exchange. (Off-exchange plans are available year-round in Nevada, with a waiting period before coverage takes effect.)

Qualifying events – because ‘life happens.’

That is, unless you have a qualifying event.

When the ACA was written, lawmakers understood the importance of limiting enrollment to specific times of the year if coverage was to be guaranteed-issue. But they also understood that some life-changing events warrant the ability to enroll in a new health plan and do not indicate that an applicant is trying to “game the system.”

Life happens. Babies are born, other coverage ends, people move. It wouldn’t make sense to force people to wait until the following January to gain coverage under a new plan following a cross-country move, or to enroll their newborn in a health plan.

The model for qualifying events and special enrollment periods already existed in other markets, including Medicare Advantage, Medicare Part D, and employer-sponsored insurance. If you get your health insurance from your employer, you’re used to the idea that you’ve got an annual enrollment period, and you can only make changes outside of that period if you have extenuating circumstances – a qualifying event.

That was an entirely new concept in the individual health insurance market in 2014, but people are getting used to it. And while enforcement of documentation to prove a qualifying event was relatively lax in the first couple years, HealthCare.gov and most of the state-run exchanges have stepped up their documentation requirements – if you’re enrolling outside of open enrollment, be prepared to provide proof of your qualifying event.

That said, rest assured that if you do experience a qualifying event, you’ll have access to a special enrollment period, regardless of when it happens during the year. Most qualifying events trigger special enrollment periods both on and off the exchanges, and special enrollment periods generally last for 60 days.

The idea of qualifying events and special enrollment periods is not new, and some of the ACA’s qualifying events overlap with qualifying events that apply in the Medicare market and employer-sponsored insurance. But there are also new qualifying events that are specific to the individual market. This guide will walk you through all of the ACA’s qualifying events and associated special enrollment periods.

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