Qualifying Life Events for an Individual Health Insurance Special Enrollment Period

Sarah Sullivan
August 3rd, 2021 July 1st, 2021 |
Read time: 6 minutes

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Most of us have been there at one time or another – through life circumstances, we find ourselves without health insurance or enrolled in a plan that’s no longer the best fit.

Fortunately, if you experience what the Affordable Care Act (ACA) considers a qualifying life event, you could be eligible for a special enrollment period to get a qualifying ACA health plan – that is, coverage that is guaranteed issue and covers the essential health benefits.

The remainder of this blog post addresses:

  • What special enrollment periods are and why we have the
  • How to know if you qualify for an individual special enrollment period
  • How COVID-19 has changed access to ACA health plans
  • Options if you aren’t able to enroll in an ACA plan

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What Are Special Enrollment Periods and Why Do We Have Them?

Special enrollment, or a “special enrollment period” is a set amount of time (typically up to 60 days) to enroll in an ACA health insurance plan or switch plans outside of the annual open enrollment period.[1]

Why can’t you enroll in major medical insurance anytime? Limiting enrollment in qualifying ACA health plans to a specified period of time is an effort to avoid “adverse selection.” Put simply, it’s meant to keep people from only acquiring coverage when they need it, such as for an upcoming surgery or after they’ve become sick, and then canceling coverage when they’re healthy so they don’t have to make premium payments.[2]

Do You Qualify for Health Insurance Special Enrollment?

There are a number of life events that could qualify you for a special enrollment period. HealthCare.gov includes the following qualifying life events:[3]

  • Loss of health coverage – This includes losing your current job-based, individual and student plans; eligibility for Medicare, Medicaid, or CHIP; and turning 26 and aging out of a parent’s plan.
  • Kids – This includes adding to your household by having a baby or adopting, or having a child removed from your household and placed in foster care.
  • Marriage/Relationship status – This includes getting married, divorced or legally separated from your spouse, however, if divorce or legal separation does not result in a loss of coverage you won’t be eligible for special enrollment.
  • Death – The death of a household member that’s on your policy may qualify you for special enrollment if it results in losing eligibility for the plan you’re currently enrolled in.
  • Changes in residence – This includes moving to a new ZIP code or county, students moving to or from the place they attend school, seasonal workers moving to or from the place they both live and work, and moving to or from a shelter or other transitional housing.
  • Other qualifying events – This includes income changes that affect the coverage for which you qualify, gaining membership in a federally recognized tribe or status as an Alaska Native Claims Settlement Act (ANCSA) Corporation shareholder, becoming a U.S. citizen, leaving jail or prison, or AmeriCorps members starting or ending their service.
    These are the most common ways to qualify for a special enrollment period; however, there may be other circumstances that qualify you.

Find out if you qualify for a special enrollment period using HealthCare.gov’s screener tool or by calling 888-855-6837 and working with a professional health insurance agent.

Special Enrollment Periods and COVID-19

The COVID-19 pandemic and subsequent actions taken by the federal government have resulted in additional opportunities to enroll in ACA coverage outside of the annual open enrollment period:

A COVID-19 Special Enrollment Period for HealthCare.gov was implemented through August 15, 2021 – Anyone that qualifies to enroll in a plan from the federally facilitated Exchange (HealthCare.gov) can enroll or change plans during this time.[4]

Extended individual special enrollment period due to COVID-19 national emergency – If you lost employer-based health coverage after January 1, 2020, you may have more than 60 days to enroll in an ACA plan if you were impacted by the COVID-19 national emergency.[5]

Due to the American Rescue Plan Act of 2021 (ARP), federal subsidies for ACA health plans have been increased and expanded through December 31, 2022.[6] This includes $0 premium plans available for qualifying lower-income households.[7]

Learn more about the 2021 COVID Relief Bill and if you qualify for advance premium tax credits if you shop on the federal Exchange.

Estimate your subsidy amount and enroll in reduced premium coverage if you qualify.

ACA Subsidy Calculator

How Long Do You Have to Enroll?

Under normal circumstances, individual special enrollment periods typically last up to 60 days after a qualifying life event.[8] To find out if you qualify for a special enrollment period and for what duration:

  • Visit HealthCare.gov and answer a few questions. This screening tool will help you determine whether or not you may be eligible and point you toward the correct state-based or federally facilitated exchange from which to begin the application process.
  • Contact your state-based or federally facilitated exchange. Find your exchange.

Avoid Coverage Gaps by Applying Ahead of Your Qualifying Event

If you know you’ll be losing coverage in the future, for example on your 26th birthday you’ll no longer be eligible to be a dependent on a parent’s health plan, you can submit an application for an ACA plan before the actual date your existing benefits terminate to help avoid a gap before your new plan takes effect.[9]

If you’re unable to plan ahead and find that you have a gap in your major medical coverage, short-term health insurance, temporary, limited coverage that is not guaranteed issue, may be an option.

Shop plans to see short-term plan options available in your area.

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Other Coverage Options if You Don’t Qualify for Special Enrollment

If it’s outside of open enrollment and you don’t qualify for a special enrollment period, you may have other health insurance options that are available year-round, including Medicaid and temporary health insurance.

Medicaid

Medicaid is an insurance program that provides free or low-cost healthcare coverage to those who meet eligibility criteria. Medicaid is considered minimum essential coverage under the Affordable Care Act and includes comprehensive benefits similar to individual major medical insurance.

You must meet your state’s eligibility requirements to enroll in Medicaid. Get info on your state’s program at Medicaid.gov.

Short-Term Health Insurance

Short-term health insurance provides temporary benefits for unexpected medical expenses resulting from injury or illness. Policies last as few as 30 days (and up to 364 in some states) and are not guaranteed issue.

If you qualify, you may begin coverage as soon as the day after your application is approved. Short-term health insurance is not minimum essential coverage, meaning these plans are not ACA-compliant, do not include all of the essential health benefits and you may be denied coverage based on your health history.

However, with fewer benefits than ACA-compliant health insurance, these options often have lower monthly premiums than unsubsidized ACA-compliant policies.[10]

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Summary + Next Steps

Remember, until August 15, 2021 you may be able to enroll in an ACA plan due to the COVID-19 Special Enrollment Period. Start at HealthCare.gov.

If it’s outside of the COVID-19 Special Enrollment or ACA Open Enrollment period, you may be able to enroll in health insurance or switch health insurance policies if you experience a qualifying life event.

If you’re not eligible for an individual special enrollment period, you may be able to find coverage through an alternative option such as Medicaid or short-term health insurance if you qualify.

Visit HealthCare.gov to see if you:

Call 888-855-6837 to speak to a licensed health insurance agent for help understanding your options.

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Originally Published On September 9th, 2015
Independence American Insurance Company and/or Madison National Life Insurance Company, Inc. may underwrite the products referenced on this website. Legal Disclaimers.

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