Publication of the first edition of the Insider’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.
Now in its seventh edition, the 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). 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.
2021: One-time special enrollment period means that the door is still open for millions
For 2021, the rules a different. Due to the ongoing COVID pandemic, the Biden administration has announced a one-time special enrollment period that runs for three months in early 2021, continuing until May 15. This window applies in the 36 states that use HealthCare.gov, but nearly all of the states that run their own marketplaces have announced similar enrollment windows. In most states, anyone can sign up or make a plan change during the COVID-related special enrollment period, although some of the state-run exchanges are limiting their enrollment opportunities to people who are currently uninsured. In either case, however, people do not need to experience a qualifying event in order to sign up for coverage during this one-time special enrollment period.
But in a normal year (and presumably after mid-May 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 (800) 436-1566 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.
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.