Life Events That Qualify for the ACA Special Enrollment Period

Have you had your own health insurance plan now? Are interested in enrolling for a Special Enrollment Period? If yes, congratulations on making a bold decision for you and your family!

special enrollment period

There are qualifying life events that allow you to have a special enrollment.

You qualify for a Special Enrollment Period (SEP) if you have certain life events like:

  • Involuntary loss of coverage;
  • Individual plan renewing outside of the regular open enrollment;
  • Having a baby/ gaining a dependent;
  • Marriage;
  • Divorce;
  • Domestic violence of spousal abandonment;
  • Becoming a US citizen or lawfully present resident;
  • A permanent move;
  • An error or problem with enrollment;
  • Employer-sponsored plan becomes unaffordable or stops providing minimum value;
  • An income increase that moves you out of the coverage gap;
  • Gaining access to a QSEHRA or Individual Coverage HRA; and
  • An income or circumstance change that makes you newly eligible (or ineligible) of subsidies of CSR.

Let’s discuss them one by one.

1. Involuntary loss of coverage

The coverage you are losing must be the bare minimum, and the loss must be unintentional. Cancelling the plan or failing to pay the premiums is not considered an involuntary loss of coverage; willingly leaving a job and so losing employer-sponsored health coverage is. In most circumstances, the loss of non-essential coverage does not trigger a special open enrollment period.

You can get a new ACA-compliant plan without a gap in coverage during your special open enrollment period. Take note: as long as your previous plan doesn’t end in the middle of the month. This begins 60 days before the termination date. You also have 60 days after your current plan expires to choose a new ACA-compliant plan.

The effective date, regardless of the day you enroll, is the first of the month following the loss of coverage; if you enroll prior to the loss of coverage. For example, if your plan is ending June 30, you can enroll anytime in May or June; and your new plan will be effective July 1.

However, if you enroll within 60 days of your current plan’s expiration, the exchange can either give you a first-of-the-month effective date regardless of when you enroll, or they can give you an earlier deadline. Prior to 2022, most states had a 15th of the month deadline. But as of 2022, this is no longer the case. Instead, coverage will begin on the first of the next month after enrollment.

2. Individual plan renewing outside of the regular open enrollment

In late May 2014, the Department of Health and Human Services (HHS) announced a regulation that includes a provision allowing for a special open enrollment for those whose health plan is renewing, but not terminating, outside of regular open enrollment.

Although ACA-compliant plans follow a calendar year timetable, this is not necessarily true for grandfathered and grandmothered plans, nor for employer-sponsored plans.

Insureds with these policies have the option to accept the renewal but are not compelled to. Instead, customers have 60 days ahead of the renewal date and 60 days after the renewal date to choose a new ACA-compliant plan.

HHS also clarified that this SEP is applicable to anyone who has a non-calendar year group plan that is about to expire. They can keep it or convert it to an individual market plan using a SEP.

Note: If the employer-sponsored plan is considered affordable and provides minimum value, the applicant is not eligible for premium subsidies in the exchange.

3. Having a baby/ gaining a dependent

Expecting a baby in the family? Becoming or gaining a dependent is a qualifying event. The date of birth, adoption or placement in foster care is used to determine coverage. Even though the child is born or adopted during the standard open enrollment period, it’s best to use a special enrollment period in this scenario. This is because of the particular regulations surrounding effective dates.

HHS’s April 2017 market stability regulation placed several new conditions on this Special Enrollment Period. If a new parent is already enrolled in a QHP, he or she can join the baby/adopted child to the plan or enroll with the new dependent in a plan at the same metal level (if for some reason the child cannot be added to the plan). Alternatively, the youngster can enroll in any available plan on their own. On the other hand, the parent can’t use the SEP to change plans and enroll the child in a new one.

4. Marriage

If you marry, you have a 60-day open enrollment period that begins on the day of your wedding. However, new laws established in 2017 have put some restrictions on this unique enrollment period. For at least one of the 60 days preceding the marriage, at least one partner must have had minimal essential coverage (or lived outside the United States or in a U.S. Territory). In other words, if neither of you had coverage prior to getting married, you cannot use marriage to get coverage.

If you qualify for a special enrollment period, your policy will go into effect on the first of the month. This happens after you submit your application regardless of when you finish it.

If you get married within the general open enrollment period, it can make sense to use your SEP. It’s because marriage triggers a specific effective date rule.

For example, if you get married on November 27, you can choose a new plan that day and start coverage on December 1. This happens if you take advantage of the SEP triggered by your marriage. If you sign up during the general open enrollment period, though, your new coverage won’t start until January 1.

5. Divorce

If you lose your current health insurance due to a divorce, you are eligible for a special open enrollment period.

If a court orders a parent to buy health insurance as part of a custody agreement, the exchange must give the parent the option of starting coverage on the date the court order was issued; albeit the parent can also choose one of the usual effective dates listed above.

Exchanges can also give a temporary enrollment period to those who lose a dependent or lose their dependent status.

Divorce without a loss of coverage does not usually trigger a special enrollment period in most states, including the 33 states that use HealthCare.gov.

6. Domestic violence or spousal abandonment

Victims of domestic violence or spousal abandonment are eligible to enroll in a plan on their own (or with their children), separate from the partner who abused and/or abandoned them. This is true whether the abuse or abandonment occurs during or after open enrollment.

In most cases, married participants are only eligible for exchange subsidies if they file a joint tax return. It also includes their total family income in their enrollment. Domestic violence or spousal abandonment victims, however, are exempt. In some cases, the victim can indicate on the exchange application that he or she is single. The enrollee’s income determines the eligibility for premium subsidies and cost-sharing subsidies.

7. Becoming a US citizen or lawfully present resident

This qualifying event only applies within the exchanges. That means, carriers providing coverage outside of the exchanges are not obligated to provide a SEP for those who get citizenship or lawful residency in the United States.

Because recent immigrants aren’t eligible for Medicaid until they’ve been in the US for at least five years, there are specific criteria that allow them to qualify for premium subsidies in the exchange even if their income is below the poverty level.

8. A permanent move

This SEP applies if you relocate to an area with a variety of qualified health plans (QHPs). This is only available to applicants who have had minimum essential coverage in force for at least one of the 60 days prior to the move.

It is important to note that moving to a hospital in another area for medical treatment does not constitute a permanent move, according to HHS, and does not qualify a person for a special enrollment term. A person having houses in more than one state can establish residency in both states and switch policies to coincide with a move between homes.

9. An error or problem with enrollment

There are a variety of errors and delays that could occur during the regular open enrollment period. To provide flexibility for the exchanges to deal with these issues, HHS included the following in the category of qualifying events:

  • Your enrollment – or lack thereof – was the result of an error, misrepresentation, misconduct, or inaction on the part of the exchange, one of its representatives, or an enrollment assister. 

  • Your eligibility determination (for Medicaid/CHIP, premium subsidies, and/or cost-sharing subsidies) or coverage effective date was incorrect, and you filed a successful appeal with the exchange.

  • A technical error occurred during your enrollment, or the plan information was incorrectly displayed on the exchange website.

  • You’re a recent immigrant (not eligible for Medicaid) with a household income under 100% of the poverty level, and you didn’t enroll in coverage while waiting for the exchange to determine your eligibility for subsidies in the exchange. 

  • You applied for Medicaid or CHIP during open enrollment. Although you were deemed ineligible, the determination wasn’t made until after open enrollment ended.

See Exceptional circumstances for special enrollment for more details.

10. Employer-sponsored plan becomes unaffordable or stops providing minimum value

In 2021, an employer-sponsored plan is reasonable. Remember, as long as the employee’s portion of the coverage does not cost more than 9.83 percent of household income.

A change in plan design may cause a plan to no longer provide minimum value. A reduction in work hours (with the resulting pay cut meaning that the employee’s insurance takes up a bigger part of their family income) or an increase in the premiums that the employee must pay for their coverage are two examples of conditions that could cause a plan to become unaffordable.

If a person’s employer-sponsored coverage isn’t providing minimum value and/or isn’t affordable, premium subsidies are available in the exchange.

11. An income increase that moves you out of the coverage gap

As previously stated, the new market stability regulations allow for a special enrollment period triggered by marriage only if at least one partner had minimum necessary coverage prior to the marriage. If two persons in the coverage gap marry, their combined income may be enough to lift their household above the poverty line, allowing them to receive premium subsidies. Even though neither of them had coverage before getting married, they would still be eligible for a SEP in that situation.

From 2022 to 2025, the Build Back Better Act would temporarily bridge the coverage gap by providing premium subsidies to persons with incomes below the coverage gap.

12. Gaining access to a QSEHRA or Individual Coverage HRA

This is a new special enrollment period that began in 2020 as a result of the Trump administration’s new health reimbursement rules, which reimburse employees for individual market coverage. Small businesses can compensate employees for the cost of individual market coverage through QSEHRAs. This was introduced in 2017 as part of the 21st Century Cures Act (up to limits imposed by the IRS). 

This includes persons who are newly eligible for the benefit. As well as those who were offered the choice in previous years but didn’t take it or only took it for a short time. In other words, anyone transitioning to QSEHRA or Individual Coverage HRA benefits — regardless of prior coverage — has access to a special enrollment period during which they can choose an individual market plan on-exchange or outside the exchange (or switch from their existing individual market plan to a different one).

This special enrollment period begins 60 days before the QSEHRA or Individual Coverage HRA benefit takes effect, allowing participants to enroll in an individual market plan that will take effect on the QSEHRA or Individual Coverage HRA’s effective date.

13. An income or circumstance change that makes you newly eligible (or ineligible) for subsidies or CSR

You’ll have the option to switch plans if your income or circumstances change, causing you to become newly eligible or ineligible for premium tax credits or cost-sharing subsidies. This rule applies to enrolled people in a plan through the exchange.

As of 2022, exchange members with silver plans who receive cost-sharing reductions will have a special enrollment period if their income or circumstances change, making them no longer eligible for cost-sharing subsidies. People in this position allow switching to a plan with a different metal level, while the existing rules only enable them to choose from among the various silver plans.

Are you qualified for SEP?

Do you belong to any of the situations given? Do you have any questions? If you need more information about SEP, call Simple Choice at 832-626-7791.

References:

Davalon. (2021). Qualifying life events under Obamacare. Retrieved January 21, 2022, from https://www.ehealthinsurance.com/resources/affordable-care-act/qualifying-life-events-obamacare

Healthcare.gov. A special enrollment period due to life change. Retrieved January 21, 2022, from https://www.healthcare.gov/screener/.

Norris, L., Exceptional circumstances for special enrollment. Retrieved January 21, 2022 from https://www.healthinsurance.org/special-enrollment-guide/exceptional-circumstances-for-special-enrollment/

Norris, L. (2022). 12 qualifying events that trigger ACA special enrollment. healthinsurance.org. Retrieved January 21, 2022, from https://www.healthinsurance.org/obamacare/qualifying-events-that-can-get-you-coverage/