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13 qualifying life events that trigger ACA special enrollment
Outside of open enrollment, a special enrollment period allows you to enroll in an ACA-compliant plan (on or off-exchange) if you experience a qualifying life event.

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Who doesn’t need a qualifying life event to enroll in health insurance outside of open enrollment?

Some applicants don’t need a qualifying event in order to sign up for coverage outside of open enrollment

If you need to obtain your own health insurance (i.e., not through your employer), you’re probably familiar by now with the fact that the individual health insurance market has an annual open enrollment period. To enroll outside of open enrollment, most applicants will need a qualifying life event to trigger a special enrollment period (SEP).

But qualifying events aren’t always necessary to trigger an SEP. Enrollment continues year-round in some cases, and you don’t need a qualifying event if you’re in one of these categories:

  • American Indians and Alaska Natives. The Affordable Care Act (ACA) has a provision that allows American Indians and Alaska Natives to enroll year-round in the exchanges. They also have access to plans with zero cost-sharing if their income is no more than 300% of the federal poverty level. In the final Benefit and Payment Parameters for 2018, HHS added a provision to ensure that dependents of American Indians can enroll on the same application as the American Indian.1
  • In nearly every state, low-income people who are eligible for premium subsidies (i.e., they aren’t eligible for Medicaid or in the coverage gap) and whose income doesn’t exceed 150% of the poverty level can enroll at any time, until at least the end of 2025. (In some states, the income limit is higher.) The federal government has proposed a rule change that would make this SEP permanent.2
  • Residents of New York who are eligible for The Essential Plan. This is a Basic Health Program (BHP) that was implemented in New York in 2016. It’s available for residents who are not eligible for Medicaid or CHIP, and whose annual household income is up to 200% of the federal poverty level (FPL). New York has received federal approval to extend the eligibility limit to 250% of the poverty level starting in April 2024.
  • Residents of Minnesota who are eligible for MinnesotaCare. This is also a BHP, and although MinnesotaCare pre-dates the ACA, it was converted to a BHP under the ACA as of 2015. The upper income limit is 200% of the federal poverty level, and enrollment continues year-round.
  • Residents of Massachusetts who qualify for ConnectorCare, as long as they are either newly eligible for ConnectorCare, or are applying for the first time. (The ability to enroll year-round in ConnectorCare does have some restrictions). ConnectorCare is available to residents with income up to 500% of the federal poverty level (this limit used to be 300%, but was raised as of 2024) and is subsidized by the state in addition to the premium subsidies and cost-sharing subsidies provided by the ACA.3
  • Residents of Connecticut who are eligible for the Covered Connecticut program. This includes adults under age 65 who are not eligible for Medicaid and whose income doesn’t exceed 175% of the poverty level. Enrollees must select a Silver-level plan through the Connecticut Marketplace (Access Health CT) and utilize all available federal subsidies.

For everyone else shopping for their own ACA-compliant individual/family health insurance – on-exchange or off-exchange – a qualifying event will be necessary to buy a plan outside of open enrollment.

Qualifying events are not necessary to enroll in plans that aren’t subject to ACA regulations, including accident supplements, critical illness plans, short-term health plans, travel insurance, fixed indemnity plans, and other limited benefit plans. So those plans can be purchased at any time during the year, as long as the applicant is eligible based on the insurer’s underwriting rules.

A qualifying event is also not necessary to enroll in  Medicaid or the Children’s Health Insurance Program (CHIP). Enrollment in these plans is available year-round, both for people who are newly eligible due to a change in income, and for people who were already eligible but not yet enrolled.

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.

 

Footnotes

  1. Health Coverage Options for American Indians and Alaska Natives” CMS.gov, Accessed March 1, 2024 
  2. Patient Protection and Affordable Care Act, HHS Notice of Benefit and Payment Parameters for 2025; Updating Section 1332 Waiver Public Notice Procedures; Medicaid; Consumer Operated and Oriented Plan (CO-OP) Program; and Basic Health Program” Federal Register, Nov. 24, 2023 
  3. Policy NG-2 Eligibility for Federal and State Financial Support for Individual and Family Plans” mahealthconnector.org, Oct. 23, 2023 

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