EDIT: This post was originally published in Mary 2014, but has been updated for 2015.
After open enrollment ends on February 15, there will be very few options for coverage that can be purchased before open enrollment begins again in October (2016 open enrollment is scheduled to run from October 1 to December 15, with coverage effective January 1, 2016). In general, the plans available outside of open enrollment without a qualifying event are not regulated by the ACA, and most are not a good choice to serve as stand-alone coverage.
There are a few exceptions: In Nevada, off-exchange carriers are required to offer year-round enrollment, but they can impose a waiting period of up to 90 days before benefits become effective. In Arizona, Meritus (an ACA-created, not-for-profit CO-OP health plan) offers year-round coverage outside the exchange, although tax subsidies are only available in the exchange, and the regular open-enrollment dates apply to Meritus plans in the exchange.
These are very rare exceptions however. The vast majority of ACA-compliant plans, both on and off-exchange, are not available for purchase outside of open enrollment.
Qualifying events
That is, unless you have a qualifying event that triggers your own special open enrollment window.
People with employer-sponsored health insurance are used to both open enrollment windows and qualifying events. In the employer group market, plans have annual open enrollment times when members can make changes to their plans and eligible employees can enroll. Outside of that time frame, however, a qualifying event is required in order to enroll or change coverage.
In the individual market, this was never been part of the equation prior to 2014 – people could apply for coverage any time they wanted. But policies were not guaranteed issue, so pre-existing conditions meant that some people couldn’t get coverage or had to pay more for their policies.
All of that changed thanks to the ACA. Individual coverage is now quite similar to group coverage. As a result, the individual market now utilizes annual open enrollment windows and allows for special open enrollment triggered by qualifying events.
So even if you don’t select a plan by February 15, you could still have an opportunity to enroll in ACA-compliant coverage this year if you experience a qualifying event. In that case, you have a special open enrollment period – generally 60 days – during which you can enroll in a new plan on or off-exchange, or switch to a different plan.
What counts as a qualifying event?
What counts as a qualifying event? In many cases, they’re the same things that count as a qualifying event for employer-based plans. But some are specific to the individual market under the ACA.
In most cases, the effective date follows the same rules that it does during regular open enrollment. So for states using HealthCare.gov and most of the state-run exchanges, that means that applications completed by the 15th of the month will be given a first-of-the-following-month effective date.
There are four states with enrollment deadlines later than the 15th of the month: Maryland is the 18th, Massachusetts, Rhode Island, and Washington are all the 23rd.
Applications received between the 16th (or the 19th or 24th if you’re in MD, MA, RI, or WA) and the end of the month will have an effective date of the first of the second following month. (Marriage, loss of other coverage, and birth/adoption have special effective date rules, described below.)
10 special open enrollment triggers
- Involuntary loss of other coverage that is qualified as minimum essential coverage. (Cancelling the plan or failing to pay the premiums does not count as involuntary loss). Loss of coverage that isn’t minimum essential coverage does not trigger a special open enrollment, but new regulations do provide one exception in the case of loss of pregnancy-related Medicaid coverage. Women who become ineligible for pregnancy-related coverage do have access to a special open enrollment period.Your special open enrollment begins 60 days before the termination date, so it’s possible to get a new ACA-compliant plan with no gap in coverage. (See details in Section (d)(6)(iii) the code of federal regulations 155.420, and the updated regulation that makes advance open enrollment possible for people with individual coverage as well as employer-sponsored coverage.)You also have 60 days after your plan ends during which you can select a new ACA-compliant plan. In that case, the effective date will be the first of the following month.
- Individual plan renewing outside of the regular open enrollment. HHS issued a regulation in late May 2014 that included a provision to allow a special open enrollment for people whose health plan is renewing – but not terminating – outside of regular open enrollment. In early 2014, the Obama Administration announced that non-grandfathered pre-2014 individual plans could be extended for up to two more years, and it was left to states and carriers to decide whether or not to do so. The result is that many health plans that were scheduled to terminate at the end of their plan year in 2014 will instead be eligible for renewal. Insureds with these plans may accept the renewal but are not obligated to do so. Instead, they can select a new ACA-compliant plan during the 60 days prior to the renewal date and 60 days following the renewal date (In November 2014, HHS proposed continuing this provision into future years).
- People who were enrolled in COBRA – even if their plan was not exhausted – had a one-time special open enrollment period that ran through July 1, 2014. COBRA enrollees were able to select a marketplace plan instead and drop their COBRA coverage. This was particularly beneficial for people who qualified for subsidies in the marketplace, since the subsidized premium was likely to be lower than the unsubsidized cost of COBRA. This special open enrollment period technically only applies in the HHS-run exchanges, but most state-run exchanges followed suit (Kentucky, DC, and Nevada did not). This special enrollment period doesn’t apply anymore though. People who are enrolled in COBRA plans can switch during open enrollment or if they have a qualifying event (including the exhaustion of their COBRA benefits) outside of open enrollment.
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Becoming a dependent or gaining a dependent as a result or birth, adoption, or placement in foster care. Coverage is back-dated to the date of birth, adoption, or placement in foster care (new regulations also allow parents the option to select a later effective date).
The current regulation states that anyone who “gains a dependent or becomes a dependent” is eligible for a special open enrollment window, which obviously includes both the parents and the new baby or newly adopted or fostered child.
But the Federally Facilitated Marketplace accepts applications for the entire family (including siblings) during the special open enrollment window. If you live in a state that is running its own exchange, check with your exchange to see how they have interpreted the regulation.
HHS has proposed expanding this special enrollment period to anyone who experiences an event that results in a changed family structure. If finalized, this provision would allow the household to select a new plan that better fits their needs following the change.
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A permanent move to an area where different qualified health plans (QHPs) are available. A permanent move to a new state will always trigger a special open enrollment period, because each state has its own health plans. But even a move within a state can be a qualifying event, as some states have QHPs that are only offered in certain regions of the state.
So if you move to a part of the state that has plans that were not available in your old area, or if the plan you had before is not available in your new area, you’ll qualify for a special open enrollment. HHS has proposed adding a special enrollment period that begins 60 days in advance of a move, in order to prevent gaps in coverage. If finalized, that provision would be effective in 2016.
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Employer-sponsored coverage reducing benefits such that it no longer provides minimum value, or becomes unaffordable (defined as requiring the employee to pay more than 9.5 percent of income for just the employee’s portion of the coverage) for the upcoming plan year.
In this case, you’ll have access to a special open enrollment window both before and after the date that your employer plan renews (similar to the scenario described above for people losing coverage).
What if you’re already enrolled?
Additional qualifying events apply to people who are already enrolled in the exchange:
Who doesn’t need a qualifying event?
In some circumstances, enrollment is available year-round, without a need for a qualifying event:
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Medicaid enrollment is also year-round. For people who are near the threshold where Medicaid eligibility ends and exchange subsidy eligibility begins, there may be some “churning” during the year, when slight income fluctuations result in a change in eligibility.
If income increases above the Medicaid eligibility threshold, there’s a special open enrollment window triggered by loss of other coverage. Unfortunately, in states that have not expanded Medicaid, the transition between Medicaid and QHPs in the exchange is nowhere near as seamless as lawmakers intended it to be.