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 Obamacare's special enrollment periods

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 sixth 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 4.7 million uninsured Americans could have qualified for free health insurance for 2020). Others simply didn’t have enough information to make a decision.

For those consumers, the end of open enrollment may sound like a door slamming shut on their coverage options. And for many, that is the case: 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.

The door is still open for millions

But for millions of others, the door to ACA-compliant health coverage is still open. If you’re one of them, our Insider’s Guide to Special Enrollment is for you.

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 2020 are mostly the same as they were in 2019, although there’s a new SEP associated with employer reimbursements for health insurance. 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.

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Special Enrollment Guide cover illustration

Special Enrollment Guide

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 an SEP
12 An SEP for your growing family
13 Exceptional circumstances for special enrollment
14 An SEP if you have a QSEHRA or ICHRA

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Allen D Blume
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Allen D Blume

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… Read more »

Louise Norris
Editor

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… Read more »