Qualifying for Coverage Outside of Open Enrollment

A special enrollment period is a period outside of open enrollment in which you can get coverage due to qualifying life events. You may qualify for special enrollment if you miss a deadline, have a change in family status, lose your plan, or have one of many hardships.

On this page we will discuss what qualifying life events will allow you to qualify for a special enrollment period in the marketplace, how other insurance types deal with special enrollment periods, and how hardship exemptions go hand-in-hand with special enrollment periods to expand your coverage options and help you avoid the fee.

Many of ObamaCare’s special enrollment periods also qualify you for exemptions.
ObamaCare’s health insurance marketplaces, employer based insurance, and other insurance types (like Medicare) all have unique special enrollment periods. Medicaid and CHIP have open enrollment all year and can be applied for retroactively.

Special Enrollment 2016 Facts

Some of ObamaCare’ Special Enrollment Periods are consistent, others change to meet the events of the day. If you didn’t finish enrollment or missed the 2016 deadline, here is what you need to know (see next section for traditional ongoing special enrollment information):

NOTE: There is no extensions for 2016 so only normal special enrollment rules apply.

  • If you signed up for the Marketplace but didn’t complete the enrollment process, you had a few extra days to complete enrollment due to a short Special Enrollment Period. Some states have unique extensions. See state extensions.
  • If you had trouble signing up or had a plan from last year, you’ll need to attest that your trouble signing-up was due to a website or call center problem. You may be granted a short special enrollment period.
  • If you got rejected from Medicaid or CHIP, the denial may qualify you for a special enrollment period.
  • If you missed the 2016 deadline and didn’t create an account, you won’t be able to get cost assistance on marketplace insurance (or an ACA-compliant private plan) until the next open enrollment period starts again in November of 2016 unless you have a qualifying life event.
  • You may qualify for Special Enrollment due to qualifying life events even if we didn’t expressly state your situation above. Contact an Insurance Agent outside the Marketplace, or go to HealthCare.Gov or your state’s marketplace now.

NOTE: For 2015 only, there was a Special Enrollment Period from March 15th, 2015 to April 30th, 2015 for those who were either confused about open enrollment or who had to pay the fee for 2014.

ObamaCare Special Enrollment Period

A special enrollment period is a time outside of open enrollment when you and your family can sign up for health insurance in the health insurance marketplace.

  • You may qualify for a special enrollment period of (typically) 60 days following certain life events that involve a change in family status (for example, marriage or birth of a child) or loss of other health coverage.
  • Job-based plans must allow special enrollment periods of 30 days (giving you no less than 30 days to switch to an employer plan from a non-employer plan). If you lose your job you get 60 days to enroll in marketplace coverage.
  • Many special enrollment periods start before you lose coverage, thus giving you time to enroll in a plan and avoid a coverage gap.
  • IMPORTANT: Even though an enrollment period starts 60 days following the day of the event, in most cases you can enroll up to 60 days before the event. This allows your coverage to start on the day of the event and allows people to avoid any gaps in coverage.
  • If you don’t have a special enrollment period, you can’t buy insurance inside or outside the Marketplace until the next open enrollment period.
special enrollment period

This special enrollment infographic is from the Maryland Health Connection, but the phone number has been updated to the official healthcare.gov marketplace hotline.

Common Special Enrollment Periods (SEP) Enrollment Windows

Not all special enrollment periods are the same length. Some life events trigger a 120 special enrollment period, some trigger a hardship exemption, some trigger shorter periods with no exemption, and some only trigger the ability to purchase outside of open enrollment. Below are common qualifying life events and enrollment windows. See full lists of qualifying events below.

NOTE: You can apply early to ensure your coverage starts on the day you would lose coverage. Even though you can enroll before the Special Enrollment window, your coverage won’t start until the day of the event or denial.

  • Losing other health coverageFrom 60 days before to 60 days after losing your other coverage
  • Being Denied Medicaid or CHIP. Up to 60 days after the denial.
  • Getting Married. Up to 60 days after the event.
  • Having a baby, adopting a child, or placing a child for adoption. Up to 60 days after the event.
  • Having a change in income or household status that affects eligibility for premium tax credits or cost-sharing reductions (if already enrolled in coverage). Only triggers special enrollment if it’s not open enrollment. Up to 60 days after the event.
  • Moving, gaining citizenship, leaving incarceration. Only triggers special enrollment if it’s not open enrollment. Up to 60 days after the event.
  • Employer special enrollment. Employer special enrollment periods typically last 30 days. If moving from a Marketplace plan to an employer plan, make sure to avoid gaps in coverage or overlapping coverage.
  • Hardship Exemptions and Enrolling in the Marketplace. Most hardship exemptions and even the act of simply enrolling in the Health Insurance Marketplace trigger a 60 day special enrollment window. Even more incentive to sign up during open enrollment or apply for a hardship exemption, even if you don’t have time to enroll properly.
While not a hardship exemption, it’s worth noting that you are allowed a coverage gap of less than 3 months each year. That covers two full months. For any other month, you’ll need to have coverage for at least one day of the month to avoid the fee unless you qualify for an additional exemption. When you qualify for special enrollment, you may qualify for additional exemptions that extend the time you can go without coverage.

Qualifying Life Events

To be eligible for special enrollment, you’ll need to meet certain qualifying life events or have a complex situation related to your applying in the Marketplace. Let’s take a look at qualifying life events first, and then we will discuss other complex situations that may qualify you for special enrollment.

The following life events will generally qualify you for a special enrollment period:

  • You signed up for the marketplace, but you were unable to complete the enrollment process for any reason (until mid-April 2014)
  • Getting married
  • Birth, adoption, or placement of a child
  • Permanently moving to a new area that offers different health plan options
  • Losing other health coverage (including job loss for any reason, divorce, loss of eligibility for Medicaid or CHIP, expiration of COBRA coverage, aging of a parents plan, or a health plan being decertified). Note: loss of coverage does not include voluntarily quitting other health coverage or being terminated for not paying your premiums. Losing coverage that is not minimum essential coverage also fails to qualify as loss of coverage.
  • For people already enrolled in Marketplace coverage, having a change in income or household status that affects eligibility for tax credits or cost-sharing reductions
  • An individual who was not previously a citizen, national, or lawfully present individual gains such status.
  • A qualified individual’s enrollment or non-enrollment in a QHP is unintentional, inadvertent, or erroneous and is the result of the error, misrepresentation, or inaction of an officer, employee, or agent of the Exchange, HHS, or its instrumentalities as evaluated and determined by the Exchange.
  • An enrollee adequately demonstrates to the Exchange that the QHP in which he or she is enrolled substantially violated a material provision of its contract in relation to the enrollee.
  • An individual is determined to be newly eligible or newly ineligible for advance payments of the premium tax credit or has a change in eligibility for cost-sharing reductions, regardless of whether such individual is already enrolled in a QHP. The Exchange must permit individuals whose existing coverage through an eligible employer-sponsored plan will no longer be affordable or provide minimum value for his or her employer’s upcoming plan year to access this special enrollment period prior to the end of his or her coverage through such an eligible employer-sponsored plan.
  • An Indian, as defined by section 4 of the Indian Health Care Improvement Act, may enroll in a QHP or change from one QHP to another one time per month.
  • A qualified individual or enrollee demonstrates to the Exchange, in accordance with guidelines issued by HHS, that the individual meets other exceptional circumstances as the Exchange may provide.

Above information compiled from healthcare.gov and section 155.420 gpo.gov Federal Register.

TIP: Applying for Medicaid or CHIP and being rejected can grant you an exemption from the fee, a special enrollment period, and if no other coverage is available, access to catastrophic coverage. You’ll need to have your rejection letter as proof to qualify for either.

Other Life Changes to Report

Not all life changes will trigger special enrollment – some may only trigger an exemption, and some may simply qualify you to change your marketplace options for coverage and cost assistance.

You should report a change if you:

  • Have a change in income
  • Become pregnant
  • Get health coverage through a job or a program like Medicare or Medicaid
  • Change your place of residence
  • Have a change in disability status
  • Gain or lose a dependent
  • Experience other changes that may affect your income and household size
  • Other changes to report: change in tax filing status; change of citizenship or immigration status; incarceration or release from incarceration; change in status as an American Indian/Alaska Native or tribal status; correction to name, date of birth, or Social Security number.

Complex Situations and Special Enrollment

While most qualifying life events are pretty standard qualifiers for special enrollment, some folks may find themselves with less common and more complex situations. Below is a list of other factors that can qualify you from special enrollment. You can see HealthCare.Gov’s complex situation’s list here.

Exceptional circumstance

You faced a serious medical condition or natural disaster that kept you from enrolling. For example:

  • An unexpected hospitalization or temporary cognitive disability
  • A natural disaster, such as an earthquake, massive flooding, or hurricane

Misinformation or misrepresentation

Misconduct by a non-Marketplace enrollment assister (like an insurance company, navigator, certified application counselor, or agent or broker) resulted in you:

  • Not getting enrolled in a plan
  • Being enrolled in the wrong plan
  • Not getting the premium tax credit or cost-sharing reduction you were eligible for

Enrollment error

The insurance company was unable to process your enrollment because of a technical error between the Marketplace and the insurance company.

System errors related to immigration status

An error in the processing of applications or system caused you to get an incorrect immigration eligibility result when you tried to apply for coverage.

Display errors on HealthCare.gov

Incorrect plan data, such as inaccurate benefit or cost-sharing information, was displayed at the time that you selected your health plan. This includes issues where some consumers were allowed to enroll in plans offered in a different area or to enroll in plans that don’t allow certain categories of family relationships to enroll together.

Medicaid/Marketplace transfers

  • If you applied for Medicaid through your state or were sent to Medicaid from the Marketplace, but you weren’t eligible for Medicaid.
  • Your state transferred your information to the Marketplace, but you didn’t get an answer about your eligibility and/or didn’t get enrolled before March 31.

Error messages

Your application was stopped due to specific error messages. For example, you received a “data sources down” error message or another error message that didn’t allow you to enroll.

Unresolved casework

You’re working with a caseworker on an enrollment issue that didn’t get resolved before March 31.

Victims of domestic abuse

You’re a victim of domestic abuse and weren’t previously allowed to enroll and receive advance payments of the premium tax credit separately from your spouse. You’ll be able to do so now.

Other system errors

Other system errors that kept you from enrolling, as determined by the Centers for Medicare & Medicaid Services.

Find Out if You Qualify

If you think you qualify for special enrollment for any of the reasons above, contact the Marketplace Call Center at 1-800-318-2596 (TTY: 1-855-889-4325)

When you call the healthcare.gov call center, a representative will ask for information about your situation to determine if your circumstances qualify you for a special enrollment period. The representative will help you apply and enroll in coverage.

If you’re already enrolled in a plan and you get a special enrollment period, you can stay in your current plan (in most cases) or you can switch plans. In some limited cases, you may qualify for an earlier effective date of coverage. Remember: you must make the first premium payment before your coverage becomes effective.

Filing an appeal

If your request for a special enrollment period is denied, you can file an appeal. If the denial is found incorrect, you can get coverage back to the date your special enrollment period was denied.

How to file an appeal:

  • Select your state’s appeal form, download it, and fill it out
  • Mail your appeal to: Health Insurance Marketplace
    465 Industrial Blvd.
    London, KY 40750-0061

When possible, include a copy of any eligibility determination notice or other official notice you received. This isn’t required, but it will help them process your appeal.

When mailing the appeal request to the Health Insurance Marketplace, be sure to include the last 4 digits of the London, KY Zip code (40750-0061). This will help your appeal arrive faster.

Hardship Exemptions

Most qualifying life events that trigger a special enrollment period also trigger a hardship exemption. This can qualify you to enroll in the Marketplace, protect you from the fee for a limited number of months, or even grant you access to catastrophic coverage.

Job Based Special Enrollment Periods

Just like special enrollment periods in the marketplace, employer coverage usually has special enrollment periods as well. In regards to job-based coverage, a special enrollment period is a time outside of the open enrollment period during which you and your family have a right to sign up for job-based health coverage. Job-based plans must provide a special enrollment period of 30 days following certain life events that involve a change in family status–for example, marriage or birth of a child–or loss of other job-based health coverage.

Medicaid and CHIP Enrollment Periods

Medicaid and CHIP don’t have enrollment periods. However, you can only use the marketplace to sign up for Medicaid and CHIP during open enrollment. If you qualify for Medicaid or CHIP, you can sign up at anytime, but you’ll have to use alternative sign up methods for Medicaid and CHIP as you won’t be able to sign up through the marketplace outside of open enrollment.

Medicare Enrollment Periods

Medicare has it’s own complex web of enrollment periods. You can find out more about specific enrollment periods for Medicare here.

I Don’t Qualify For Special Enrollment, What Other Health Insurance Options Do I Have?

If you don’t qualify for special enrollment, you still have health insurance options. If you don’t qualify for subsidized insurance or public health options, your best course of action will be to simply speak to an agent or provider and purchase private insurance outside of the marketplace. While many insurance options outside of open enrollment aren’t ACA compliant and won’t help you avoid the fee, they can help you cover your medical costs and needs. Please make sure you understand minimum essential coverage (the type of coverage needed to avoid the fee).

What If I Don’t Obtain Health Insurance?

If you don’t obtain health health insurance, you will owe 1/12 of the yearly fee for each month you go without coverage. Keep in mind that you are allowed a short coverage gap of less than three months without insurance (less than four if you signed up for a plan that started by May 1st, 2014).

If you qualify for a special enrollment period and get insurance, but you have 3 or more full months in a row without insurance, it is possible that you will owe the fee for those excess months even though you now have coverage. If you don’t get covered at all, you can’t use the exemption.

Remember, you aren’t considered covered until your plan starts and you pay your premium, so don’t calculate your fee based on when you signed up; calculate it based on when your plan started. Learn more about the individual mandate.


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