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Special Enrollment Period for Major Medical Coverage

Open enrollment for major medical coverage runs in the fall each year. For 2019 health insurance, you’ll have from November 1 through December 15 to choose a health plan or change an existing policy. Outside of that open enrollment period, the only chance you have to get private major medical coverage – the kind you get if you don’t have options via work – is through a special enrollment period. In certain situations, this Affordable Care Act provision can help you gain a traditional health plan even if you’ve missed the standard signup window. But special enrollment periods aren’t available to everyone, and they can’t always help you buy a brand new policy (i.e., your first plan of the year). Understanding the ins and outs of special enrollment periods could help you get coverage you need when you need it.

Open Enrollment

As we mentioned above, Americans have the opportunity to sign up for individual or family health insurance plans just once a year, which takes place in the fall. If you miss this window, you may not have another opportunity to buy a major medical plan until the following year. For both 2018 and 2019 health insurance signups, the federal government has limited this open enrollment period to about six weeks. Before last year, the open enrollment period lasted for three months. Some states still abide by that schedule. But in almost every state, enrollment runs from November 1 through December 15 for coverage starting on January 1.

Of course, life changes fast, and it doesn’t always change on a neat schedule that aligns with open enrollment. Rules about insurance signups might be strict, but there are some permissible exceptions. The ACA included a special enrollment period as an option for people who experience a significant change in life circumstances during the year. To qualify, you must meet specific guidelines.

Qualifications for a Special Enrollment Period

Certain qualifications will allow you to get a brand new policy no matter the time of year, but most will only allow you to switch from one major medical plan to another. In other words, you have to have a major health insurance plan in place already to take advantage of a special enrollment period in many cases.

Brand New Coverage

In limited circumstances, you can use a special enrollment period to sign up for your first major medical plan of the calendar year. You don’t need to provide proof of previous coverage to qualify. These circumstances include:

  • Having a baby, adopting a child or receiving a foster placement
  • Getting released from prison
  • Increasing your income to the point that you’ve moved out of the Medicaid coverage gap and now qualify for premium tax credits

These situations give you a chance to sign up for a health insurance policy outside of open enrollment, and you don’t need to already have a health plan in place to do it.

Changing Plans

For most life changes, however, the ACA requires that you already have a policy in place to take advantage of a special signup period. Unless you’ve been covered by a major medical plan at some point in the last 60 days, you won’t be able to claim a special enrollment period for these situations. This type of signup window is designed to allow you to switch plans at times when your original coverage is no longer available to you. Examples include:

  • Losing job-based insurance
  • Losing Medicaid or pregnancy-based insurance coverage
  • Getting married, divorced or legally separated
  • Moving to an area where your previous plan is no longer available
  • Increasing or decreasing your income, which may change your eligibility for cost assistance

While these situations still open up an enrollment period for you, it’s not meant for people who haven’t been covered before. Instead, you’ll be given the chance to switch to a new health plan that meets your new needs. If you get married, for instance, then you might want to switch to a new family health plan that includes coverage for your spouse.

Non-Qualifying Events

Not all changes make it possible for you to get a special enrollment period. In particular, you won’t qualify for a special signup window if you:

  • Voluntarily drop your health insurance
  • Lose your coverage because you didn’t pay your premiums
  • Have a short term health insurance plan and the contract for it ends

These events will all result in your losing your health insurance, but they don’t count as a situation that opens up a special enrollment period. Since short term health insurance doesn’t count as minimum essential coverage, losing your coverage won’t let you enroll in a major medical policy outside of open enrollment.

How to Apply for Health Insurance Outside of Open Enrollment

If you aren’t sure whether you qualify for a special enrollment period, your best option is to go ahead and start the application process. Answering the screening questions will help determine your eligibility. You can apply for a special enrollment period through the health insurance marketplace or through an off-marketplace source.

On the Marketplace

When you visit the federal marketplace at outside of the normal signup period, you’ll be greeted with a reminder that open enrollment has ended (assuming it’s not during the November 15 through December 1 window). Look closely, however, and you’ll spot options for special enrollment.

The federal marketplace presents two different options. If you don’t have major medical coverage, click “See If I Can Enroll.” If you currently have a health insurance plan or just recently lost coverage, choose “See If I Can Change.”

After selecting one of those options, you’ll be given the chance to use the screening tool or to fill out an application. The screening tool is a fast way to learn whether you might be eligible, but it doesn’t serve as a final ruling on the matter. The application, on the other hand, is a process through which you can receive an official determination of eligibility.

Off the Marketplace

The process for applying through an insurer, agency website or independent marketplace (like this one) is similar, but it may vary among companies. Look for wording on the insurer’s website that references special enrollment periods or qualifying life events. Click the corresponding link, and you’ll probably be taken to a screening tool. Fill in the required information to begin the process.

Special enrollment periods can be confusing. If you need help to determine your eligibility, you can reach out to the federal or state marketplace call center depending on where you live, which can give you guidance on how to shop using a government exchange. For help from a non-government source, you can contact an insurance agent or a broker. Independent insurance exchanges and private health insurance companies also have representatives who can help.

Heads Up: You’ll Need Proof

The government won’t just take your word for it that you’ve experienced a major life change and need a special enrollment period. You’ll be required to submit proof that you meet the necessary qualifications. For example, if you’re claiming a special enrollment period because you got married, you may need to submit a marriage license. If your claim is based on losing your previous major medical policy, you may need to submit the paperwork that you received from that insurer.

After submitting your application, you’ll receive a notice if documentation is necessary. If you don’t get a notice, then nothing is required. The government has cracked down on this requirement, too, since plenty of people were abusing the special signup period in the past. Be prepared to back up your request with the right documents.

Electronically uploading the documents to the marketplace is the fastest and easiest submission method, but you’ll also have the option to mail photocopies. You’ll be given a 30-day window for completing the process, and you won’t be able to use your health insurance until you’ve done so.

Dates to Keep in Mind

Important dates vary depending on why you need a special enrollment period, but there are some general dates and deadlines to keep in mind if you plan on applying for one.

Application Dates

You should apply for a special enrollment period within 60 days of your situation. The sooner you apply, the sooner your new coverage can begin. For some life changes, you may be able to submit your application up to 60 days ahead of time. This advance availability may be helpful if you know that you’ll be:

  • Moving
  • Losing your job-based coverage
  • Getting released from prison

These situations typically come with some advanced warning, so look into your health insurance options ahead of time if you know that you’re going to lose your coverage.

Start Dates

Major medical coverage that you buy during a special enrollment period usually begins on the first day of the month after you apply. If you submit your application in the first half of one month, your coverage may begin on the first day of the following month. If you wait until the second half of the month to apply, your plan might not start until the first day of the month after next. If you apply on February 11, for instance, then your coverage could start on March 1. But if you waited a week and applied on the 18th, your coverage may not start until April 1.

The rules differ a bit for special enrollment periods triggered by births, adoptions and foster placements. Your new coverage can start retroactive to the date that your child first joined your family. So for example, if your son is born on August 13 but you wait to apply for coverage until the end of September, his coverage could be effective back to his actual birth date.

Note that no matter when you apply for health insurance during a special enrollment period, your coverage won’t start until you’ve submitted the required documents and paid your first month’s premium.

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