What Is a Special Enrollment Period for Health Insurance?

Qualifying Events That Trigger a Special Enrollment Period

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Having a baby qualifies this family for a health insurance special enrollment period. Image © Matt Carr/Getty Images

A special enrollment period is a time when you’re allowed to make changes to your health insurance plan even though it’s not an open enrollment period.

Normally, you’re not allowed to sign up for health insurance or make any health plan changes except during the annual open enrollment period. However, certain qualifying events will trigger a special enrollment period allowing you to make changes for a brief period of time after the triggering event.

If you don’t make the necessary changes to your health insurance during the special enrollment period, usually about a month, you’ll have to wait until the next open enrollment period to make any changes.

What Qualifying Events Trigger a Special Enrollment Period?

Things that change the size of your family or cause you to lose other health insurance coverage are likely to trigger a special enrollment period. Examples include:

  • Divorce leaves you uninsured
  • Marriage
  • Birth of a child
  • Adoption of a child
  • Death of a spouse leaves you uninsured
  • Loss of your spouse’s job-based health insurance
  • Loss of your own job-based health insurance
  • Reduction in work hours makes you ineligible for health insurance
  • A Qualified Medical Child Support Order
  • You move outside of your HMO’s coverage area

Qualifying Events Are Similar But Not Identical in Individual Market

Prior to 2014, qualifying events and special enrollment periods applied in the group market (ie, job-based insurance) and for Medicare, but not for the individual market.

There was no open enrollment period in the individual market before 2014, and health plans were not guaranteed issue at any time of the year in most states - so there was no need for special enrollment periods; people simply applied, and were either accepted or declined by the insurance carriers.

But that changed with the Affordable Care Act.

The individual market now has special enrollment periods just like the employer-sponsored insurance market. They are very similar to the qualifying events that trigger special enrollment periods for employer-sponsored insurance and Medicare coverage, but there are some differences. If you're shopping for health insurance in the individual market (on or off-exchange), make sure you understand how qualifying events work for individual plans.

How Does a Special Enrollment Period Work?

Here’s an example:

  • Melissa, Ken, and their five children have health insurance through Ken’s job. Melissa also works. Her job offers health insurance to her but not to her dependents. During the last open enrollment period, Melissa turned down the opportunity to get health insurance through her job because it was cheaper to cover herself with a family plan through Ken’s job.
  • Ken’s hours get cut to part time. Part time employees don’t get health insurance coverage where Ken works. The entire family loses health insurance coverage. This triggers a special enrollment period for Melissa’s job-based health insurance as well as a special enrollment period on the health insurance exchange in Melissa and Ken’s state.
  • Melissa has a 30 day special enrollment period to sign herself up for health insurance at her job even though she previously waived that insurance. If she doesn’t act during these 30 days, she won’t be able to sign up at her job until her employer’s next open enrollment period.
  • Since Melissa’s employer doesn’t offer family coverage, Ken and the kids will get their health insurance at their state’s health insurance exchange. They have a 60 day special enrollment period to enroll in that health insurance. If they don’t enroll during those 60 days, they won’t have another opportunity to enroll in health insurance through their state’s health insurance exchange until the next annual open enrollment period.
  • While Ken and the kids are enrolling for health insurance on their state's exchange, they also apply for a premium subsidy. If they're eligible, the subsidy will pay for part of their monthly health insurance premiums. This will help out while finances are tight due to Ken's reduced work hours.

More About Job-Based Health Coverage

Sources:

Cornell University Law School, Legal Information Institute; 29 CFR 2590.701-6 - Special enrollment periods. Accessed 5/25/16.

Cornell University Law School, Legal Information Institute; 45 CFR 155.420 - Special enrollment periods. Accessed 5/25/16.

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