find a plan

Insider’s Guide to Obamacare’s Special Enrollment Periods

What millions of consumers don't know about qualifying life events can't help them capitalize on the Affordable Care Act's special enrollment periods

Publication of the first edition of healthinsurance.org’s Guide to Obamacare’s Open Enrollment in 2014 was our response to readers’ frequent requests for information about their enrollment options under the Affordable Care Act.

Our guide has helped thousands of readers successfully navigate the Affordable Care Act’s annual open enrollment period and find affordable, quality health insurance – either through the health marketplaces or off-exchange. We’re proud to have been part of the decrease in the national uninsured rate.

We do know, of course, that not everyone eligible for ACA-compliant health coverage bought coverage during the most recent open enrollment period. Some folks may not have enrolled because they somehow missed the enrollment deadlines. Others may have thought coverage was too expensive, or weren’t aware that they were eligible for the ACA’s premium subsidies (which are substantial enough that 4.5 million uninsured Americans could qualify for free health insurance for 2021, even before the American Rescue Plan significantly increased the number of people eligible for premium-free coverage). Others simply didn’t have enough information to make a decision.

But depending on the circumstances, people can still enroll in health coverage even after open enrollment has ended, if they experience a qualifying event. This guide will walk you through all the qualifying events and the specific rules for how they trigger special enrollment periods.

Special enrollment periods are normally required in order to buy coverage outside of open enrollment

In a normal year (and presumably after mid-August 2021), enrollment outside of the open enrollment window is only available if you experience a qualifying event. It doesn’t matter how healthy you are, or whether you’ve had continuous coverage or how much you’re able to pay – enrollment is simply not available for most of the year without a qualifying event.

And that’s where our Insider’s Guide to Special Enrollment comes in.

Louise Norris, a highly regarded expert on health insurance and author of our first guide, has put together an authoritative overview of special enrollment periods and the qualifying events that trigger those SEPs. [Note that this guide is specific to special enrollment periods in the individual market; the special enrollment period rules that apply to employer-sponsored plans are similar, but not entirely the same.]

During most SEPs, an individual (and dependents) can enroll in any health plan available in the exchange (as discussed later in this guide, some SEPs have restrictions for plan changes that limit people to a plan at the same metal level they already have). And most of the SEPs also apply to health plans available outside the exchange.

As a licensed agent, the author has seen them all – obvious triggers like loss of coverage due to divorce or legal separation, and not-so-obvious triggers such as an increase in income that makes someone newly eligible or newly ineligible for exchange subsidies.

The qualifying events that trigger special enrollment periods in 2021 are mostly the same as they were in 2019 and 2020, although there have been some additional SEPs added (for employer reimbursement of health insurance premiums, for example, and for people who have off-exchange coverage and then experience an income change that makes them newly eligible for premium subsidies in the exchange) and some that are pending approval. And as has been the case in the past few years, you’ll generally need to be prepared to provide proof of your qualifying event, although this has been relaxed somewhat for people who lose employer-sponsored coverage during the COVID-19 pandemic.

In most cases, a special enrollment period is only available if you already had minimum essential coverage before the qualifying event, and there are restrictions that prevent people from using SEPs to upgrade to better coverage during the year. Some of these restrictions and nuances have been added over the years, so the rules aren’t the same as they were in the beginning.

If you’re reading this guide and feel paralyzed in the “off-season” – the 10.5 months outside of open enrollment – don’t despair. It’s possible you already have a qualifying life event. And if you don’t right now, there may be one just around the next corner. If you’re uncertain about your eligibility for a special enrollment period, call (866) 686-8071 to discuss your situation with a licensed insurance professional.

We hope you find this guide useful – and if you do – we hope you’ll share it with someone else who needs the information.

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
15 Comments
Oldest
Newest Most Voted
Inline Feedbacks
View all comments
Allen D Blume
Allen D Blume
1 year ago

My wife and I have recently relocated from Minnesota to North Dakota and are looking for a “best value” Medicare supplemental insurance provider. We have been drawing Medicare benefits for several years, and we have a UCare Classic ™ supplemental package that provides for very good quality coverage – extensive medical care and biannual dental prophylaxis – but it will expire 30 days from our formal declaration of residency in North Dakota.
What are our insurability options? Are there rated/ranked packages available from major underwriters (Specifically Blue Cross & Blue Shield, but others comparable to UCare) and where would we find these rankings? Are there insurance providers who cover more than biannual dental cleanings?
Finally, where could I obtain side-by-side pricing and service comparisons for companies operating in North Dakota?
Thank you for your assistance,
Allen D. Blume
240 7th St. NE
Valley City, ND 58072
(703) 399-4884 C
adb8917@earthlink.net

Louise Norris
Louise Norris
1 year ago
Reply to  Allen D Blume

Allen,
I believe the plan you have is actually a Medicare Advantage plan, as opposed to a Medicare Supplement (Medigap) plan. Since your coverage under the plan you have now is ending, you’ll have the option to select a new Medicare Advantage plan, or to switch to Original Medicare plus a Medicare Supplement plan that’s offered in North Dakota .
Most Medicare Advantage plans include prescription drug coverage and dental coverage, although the specifics will vary by plan. If you opt for Original Medicare plus a Medigap plan instead, you’ll want to purchase a separate Part D plan in order to have prescription drug coverage.
Medicare Advantage plans and Part D plans are rated on a five-star rating system. Medigap plans do not have a star-rating system, but the plans are standardized, with letter designations for names. So a plan with the same letter name will offer the same benefits, regardless of which insurer offers it (pricing and how the rates change over time will vary from one insurer to another).
You can use Medicare’s plan finder tool to see what’s available in your new area: https://www.medicare.gov/plan-compare/#/?lang=en
Our Medicare site will also likely be useful to you: https://www.medicareresources.org/medicare-benefits/ It has extensive resources about Medicare Advantage, Medigap, Medicare Part D, and a summary page for North Dakota: https://www.healthinsurance.org/north-dakota-medicare/
We also recommend that you reach out to the North Dakota State Health Insurance Counseling Program – they can answer questions you have about Medicare plans that are available in North Dakota: https://www.shiptacenter.org/about-medicare/regional-ship-location/north-dakota

stephen
stephen
1 year ago

we have moved out of the country for a year, so i want to cancel my policy. when I return, is that considered a qualifying event that allows me to reinstate coverage?

Louise Norris
Louise Norris
1 year ago
Reply to  stephen

Yes, that would trigger a special enrollment period. This is explained in more detail in this section of the guide: https://www.healthinsurance.org/special-enrollment-guide/how-your-big-move-can-trigger-an-sep/
In most cases, a move only triggers a special enrollment period if you already had minimum essential coverage prior to the move. But there’s an exception for people moving to the US (or back to the US) from abroad. So when you return to the US, you’ll be able to select a new plan, even if it’s outside of open enrollment. Be aware, however, that you may have a gap between when you actually arrive in the US and when your new policy can take effect, so you’ll probably need to maintain travel insurance for a little while when you first come back.

Elaine Miller
Elaine Miller
1 year ago

I am planning early retirement in January of 2021. I believe I have the option of Cobra for 18 months. If this is the case, my Cobra will run out end of June 2022. Would that be considered a qualifying event? On the other hand could I sign up for “Obamacare” during open enrollment in Dec 2021, but have coverage take effect in July 2022?

Louise Norris
1 year ago
Reply to  Elaine Miller

Yes, the expiration of your COBRA coverage will count as a qualifying event and will trigger a special enrollment period. (and no, you can’t enroll during open enrollment in late 2021 and have the coverage effective date delayed until July 2022, so utilizing the special enrollment period is your best bet).
The qualifying event in this case is loss of other coverage, as explained here: https://www.healthinsurance.org/special-enrollment-guide/involuntary-loss-of-coverage-is-a-qualifying-event/ If you enroll in the two months prior to the end of your COBRA coverage, you’ll be able to have seamless coverage, with your new plan taking effect July 1. You can also enroll in the 60 days after your COBRA ends, but then you’d have a gap in coverage.

Clare Rockenhaus
Clare Rockenhaus
1 year ago

My daughter, 24 years old, is unemployed as of 10-31-20. She had health insurance through her job that is now gone. She went on her dad’s workplace plan, but he is retiring 1-1-21. He will use COBRA but it’s too expensive to also cover our daughter. Can she apply for a marketplace plan during open enrollment for a start date of coverage 1-1-21? We live in Kansas, which has not expanded Medicaid. She is looking for a job, and should be able to find something that makes at least minimum wage.

Louise Norris
Louise Norris
1 year ago

Yes, she can enroll during open enrollment for a plan that starts 1/1/21. In order to qualify for a premium tax credit (premium subsidy), she’s going to need to have a 2021 income of at least $12,760 (assuming she files her taxes as a household of one). If she can get a job that pays at least that much, she’ll be eligible for substantial subsidies that will cover a good deal of the premium cost for a plan purchased through the exchange. If she ends up getting a job during 2021 that provides health benefits, she’ll be able to cancel her marketplace plan at that point.

Jason
Jason
3 months ago

Hi Louise, first of all the phone number listed at the bottom of your article doesn’t seem to be working. My wife of 3 years is finally immigrating to the U.S. When I signed up for health insurance through my (new) job a few months ago, I was told that marriage is a qualifying event but immigration isn’t. This makes no sense to me, as I was unable to add my wife to my policy at that time due to her not having a social security number. Now that she’ll be getting one in the near future, that must qualify her to be added to my insurance, right? I’m looking for something concrete to go to my employer with because I don’t believe they will let me do anything before the next open enrollment if I can’t tell them exactly why they should. Thank you for the article.

Last edited 3 months ago by Jason
Louise Norris
Editor
3 months ago
Reply to  Jason

Congratulations on your wife’s immigration. Unfortunately, your employer may be correct here. Gaining lawfully present immigration status is a qualifying event for enrolling in a plan through the health insurance marketplace: https://www.healthinsurance.org/special-enrollment-guide/citizenship-status-can-deliver-coverage/

But it’s not listed as one of the qualifying events that trigger a special enrollment period for an employer-sponsored plan, as those follow somewhat different rules: https://www.law.cornell.edu/cfr/text/29/2590.701-6#a_2

For comparison, the qualifying events for individual/marketplace coverage do include gaining lawfully present immigration status: https://www.law.cornell.edu/cfr/text/45/155.420 (see section (d)(3), which refers to the fact that a lawfully present immigration status is necessary in order to enroll in the exchange, and that newly gaining that status is a qualifying event).

So your wife would be able to enroll in a plan through the marketplace until your group’s open enrollment period. At that point, you’d be able to add her to your group plan if you choose to do so (note that she would not be eligible for a subsidy in the marketplace if she’s eligible to be covered under your group plan and the coverage they provide is comprehensive and considered affordable for you, even if she isn’t enrolled in the group plan).

Jason
Jason
3 months ago
Reply to  Louise Norris

Thank you!

Marilyn Corbin
Marilyn Corbin
3 months ago

Thanks for this information. My son recently graduated from college and his health plan has now expired. He hasn’t found a job yet, so we need to get him on a plan. He’s an Idaho resident and we are in CA. I am a member of a healthshare ministry, which has been okay for me, but I don’t know if it’s a good choice for him, as he has a pre-existing condition .My husband is not working and has benefits through the VA. My son will still be considered a dependent on our 2021 tax return, so our entire household income will be considered in calculations, making YHI health plans unaffordable for him. Any ideas?

Louise Norris
Editor
3 months ago
Reply to  Marilyn Corbin

Has he obtained quotes for plans available through YHI, and if so, did he look at the Catastrophic plans? Those are very similar to Bronze plans (but they provide three office visits with copays before the deductible is met), but less expensive in terms of monthly premiums if the person isn’t subsidy-eligible.

If he wants to enroll in a plan through YHI, he’ll need to sign up within 60 days of his prior coverage ending. Otherwise, he’ll need to wait for open enrollment, which starts November 1. I assume he won’t be your tax dependent in 2022? In that case, he’ll be able to sign up for his own coverage through YHI during the open enrollment period. If he still has little to no income at that point, he’d likely qualify for Medicaid, since Idaho has expanded Medicaid eligibility for adults under the ACA. If it looks like he’ll earn more than $17,775 in 2022 (but still need to obtain his own health insurance), he’ll be able to enroll in a plan with a subsidy.

CL Caudle
CL Caudle
1 month ago

I just realized that the income limits were higher for 2021 (no cap) for subsidies. I purchased a BCBS policy in NC not through the market place. Is it too late for me to take advantage of a subsidy for 2021?

Louise Norris
Editor
1 month ago
Reply to  CL Caudle

Unfortunately, yes. There’s no way to go back and claim the premium tax credit if your coverage was purchased outside the marketplace. You might be able to transition to a marketplace plan for December, if you’ve got a qualifying life event at this point. But that would only give you the subsidy for the month of December.

The good news is that the income cap has also been eliminated for 2022. So you can enroll in a marketplace plan now, with coverage effective January 1, and you’ll be able to claim the premium tax credit for 2022.

15
0
Would love your thoughts, please comment.x
()
x