ACA Special Enrollment Period: What Is It? How Does It Work?

A special enrollment period is an opportunity for someone to get a health insurance policy outside of the regular open enrollment (2016 enrollment starts November 1, 2015 and ends January 31, 2016). There is a long list of qualifying events that allow people to purchase a health insurance policy through a state or the federal exchange during a special enrollment period. Most are significant life changes and enable the qualified applicant to purchase a policy from a marketplace within 60 days of their qualifying event. 

Qualifiers for Special Enrollment Periods

Below are a number of events and circumstances that enable someone to apply for health insurance during a special enrollment period. Anyone interested in purchasing a health insurance policy through an exchange should take advantage of special enrollment if they qualify in order to fulfill the individual mandate.

Qualifiers for Special Enrollment Periods (SEPs)
Having a baby or adopting a child Marriage or divorce
Losing job-based health insurance Medicaid and CHIP
Member of U.S. armed forces COBRA
Giving up a child for adoption Indian tribes and Alaska Natives
Other exceptional events and circumstances Victims of domestic violence
Enrollment system errors Released from incarceration

Having a baby, adopting a child or fostering a child

All three of the above events qualify someone for a special enrollment period. Beginning with the date of birth, or the date of the adoption or foster placement, the applicant has 60 days to enroll in a new health insurance plan to provide coverage for the new addition.

Supporting Documents: Required proof include birth certificate, hospital discharge paperwork (with newborn's name) or court documents showing the effective date of custody. 

Giving up your child for adoption or placing your child in foster care

If you elect to or are mandated by a court to place your child in foster care or give them up for adoption, you qualify for a special enrollment period and have 60 days from the qualifying event to shop for a new health insurance policy.

Supporting Documents: For this qualifier, you'll need to provide court documents showing a cease in obligation and the effective date.

Marriage or divorce

Marriage and divorce are both qualifiers for special enrollment periods. Both you and your spouse will be able to shop and apply for new health insurance coverage on the federal or state exchanges based on your new status.

Supporting Documents: A copy of a marriage certificate or court documents including the effective date of divorce.

Losing existing job-based health insurance

If anyone loses employer or job-based health insurance coverage, whether they leave their job voluntarily or involuntarily, they are eligible to apply for a special enrollment period. This includes the circumstance in which the job-based health insurance of someone's spouse no longer covers them. For example, if a husband loses health insurance (which was provided through his employer's group plan) and his wife was listed on the policy, she would no longer have health insurance but would be eligible for a special enrollment period lasting 60 days.

Supporting Documents: A termination notice from an employer or an indicator from the job-based insurer that coverage was lost.

Exceptional circumstances

Those subject to exceptional circumstances that prevented them from participating in the open enrollment period can apply for a special enrollment period lasting 60 days. Some of the qualifying circumstance include hospitalization or temporary cognitive disability.

Supporting Documents: A hospital bill or discharge paperwork.

Misinformation or misrepresentation  

Anyone subject to misinformation or misrepresentation by a non-marketplace enrollment assistant including an insurance company, navigator, certified application counselor, agent or broker, can apply for a special enrollment period. For example, any misconduct on the part of the assistant that results in the enrollee not getting a plan, enrolling in the wrong plan or failing to get the premium tax credit or cost-sharing reduction they are eligible for, would qualify as misinformation or misrepresentation. Once a letter acknowledging the circumstance from the appropriate exchange (either state or federal) is received by the applicant's insurer, a 60-day special enrollment period would begin.  

Supporting Documents: Letter acknowledging the circumstance from the appropriate exchange (either state or federal).

Enrollment (or marketplace-insurer error) and system or display errors

It is nearly impossible to avoid technical errors entirely when launching any website and HeathCare.gov and the state exchanges are not immune to them. Errors that occur between a marketplace and insurer, while processing an applicant’s immigration status or in a marketplace display online are not the fault of an applicant. For that reason, if any of the aforementioned errors occur and prevent someone from purchasing health insurance on the exchanges during open enrollment, they can apply for a 60-day special enrollment period.

Supporting Documents: Letter acknowledging the circumstance from the appropriate exchange (either state or federal) will be required the the applicant's insurer. 

Anyone eligible for Medicaid and the Children’s Health Insurance Program (CHIP)

Medicaid and the Children’s Health Insurance Program (CHIP) provide free or low-cost health coverage to those eligible in the U.S. Anyone can apply to both programs anytime, all year. HealthCare.gov encourages those who think they might qualify and are in need of health insurance to apply immediately. 

Medicaid is available in all states to some low-income individuals, families and children, pregnant women, the elderly and people with disabilities. Some states also have expanded their Medicaid coverage to include all adults under a certain level of income. 

CHIP also is available in all states and provides health coverage to children in families that earn too much money to qualify for Medicaid. In some states, CHIP also covers parents and pregnant women. Children can stay on their parent’s health insurance plan until the age of 26, in most cases, even if they are married, have a child, start or leave school, live with their parent’s home or aren’t claimed as a tax dependant.

Indian tribes and Alaska Natives

Like anyone eligible for Medicaid and CHIP, American Indians and Alaska Natives can apply for health insurance through the marketplace anytime, all year long. They do not need to apply for a special enrollment period to apply for health insurance. Some might even have new health coverage benefits and protections through the federal health insurance marketplace, according to HealthCare.gov. 

The Indian Health Care Improvement Act (IHCIA) was made permanent as part of the Affordable Care Act in 2010. Those who qualify for services from the Indian Health Service, tribal program or urban Indian program also have special cost and eligibility rules and qualify for Medicaid and CHIP more easily as a result.  

Others who are eligible for special enrollment periods

Members of the U.S. armed forces returning from active duty service are eligible to apply to for a 60-day special enrollment period. Supporting documentation includes forms provided by the Department of Military and Veteran Affairs.   

Survivors of domestic violence, abuse or spousal abandonment are eligible for a 60-day special enrollment periods and can apply separate from their abuser or abandoner. Those married to their abuser or abandoner can apply as if they were unmarried without fear or penalty of falsely stating their marital status.

Those who have been incarcerated - served a term in jail or prison -  also are eligible to apply for a special enrollment period. Anyone living at home or in a residential facility under the supervision of the criminal justice system do not qualify. Anyone in jail or prison pending a disposition of charges (being held but has not been convicted of a crime) is not considered incarcerated and does not qualify for special enrollment. 

Circumstances that are not qualifiers: Pregnancy and cancelling COBRA continuation

Some life events are not qualifiers for special enrollment periods. For example, pregnancy is not a qualifier, even though maternity care and childbirth are considered essential health benefits and required to be covered by all plans under the Affordable Care Act. It is an uncommon circumstance but it is possible for someone to find themselves without insurance to cover the cost of childbirth and maternity care. Some health insurance plans established prior the Affordable Care Act do not cover maternity care and have been grandfathered and are still in effect today. If someone with such a policy is interested in purchasing a new health insurance plan, they will need to do so during open enrollment. 

The Consolidated Omnibus Budget Reconciliation Act (COBRA) provides workers and their families that lose their job-based health coverage to choose whether they would like to continue their group plan benefits for a limited period of time. There are a number of qualifying events COBRA can apply to, including voluntary or involuntary job loss, reduction in the hours worked, transition between jobs, death, divorce, and other life events. These changes make consumers eligible for a special enrollment period. 

However, consumers should carefully consider a few questions before electing to receive COBRA continuation coverage. COBRA participants can be required to pay for their continuation coverage and their premiums are determined by costs paid by group plan employees, the employer and an additional 2% for administrative costs. That financial burden could be greater than the the premium one might pay for a marketplace plan and canceling COBRA continuation coverage is not a qualifying event. So unless an individual cancels their COBRA coverage during an open enrollment period, or another qualifying event to circumstance occurs, they would be left without health insurance. The expiration of someone’s COBRA continuation coverage is considered a qualifying event though.

Application Process for Special Enrollment Periods

The application process for a special enrollment period is very similar to an open enrollment period. Anyone signing up for either one must create an account, either with HealthCare.gov or a state marketplace, supply the necessary information and select an account. However, those applying for a special enrollment period must also complete what is commonly called a “Qualifying Life Event” form provided by the health insurance company they are interested in purchasing a plan from. In some cases, applicants can apply up to 60 days before an expected event occurs, ensuring there is no gap in their healthcare coverage.

If your qualifying event happens to occur during open enrollment, you can apply like anyone else without the need of showing qualifying documentation. Below is a chart showing when your new coverage can begin, assuming the date a qualifying event occured.

Qualifying Event on or before This DateCoverage Will Begin on
November 15, 2015 December 1, 2015
December 1, 2015 December 15, 2015
December 15, 2015 January 1, 2016
December 16, 2015 February 1, 2016
February 1, 2016 Will need to apply for a special enrollment period

The Centers for Medicare and Medicaid Services (CMS) announced a new Special Enrollment Confirmation Process in February of 2016

The new Special Enrollment Confirmation Process is modeled after confirmation approaches used by the Internal Revenue Service and is intended to curb abuse of the special enrollment period. Misrepresentation could result in termination of the health insurance plan an applicant enrolled in. 

Filing an Appeal after Denial of a Special Enrollment Period

If someone’s application for a special enrollment period is denied, they can file an appeal. Depending on the state the applicant files the appeal from, there are one of three possible appeal documents. Once someone has located the document for their state, it must be printed, completed and either mailed or faxed to the Health Insurance Marketplace. The appeal documents, mailing address and fax number are below. 

While an appeal is being processed, HealthCare.gov might ask for additional informaiton such as a copy of the applicant’s passport. The organization says on its website that it uses the additional identification “to informally resolve your case fairly quickly.” The organization also states on its website, “In general, we must tell you our decision and mail our response within 90 days of when we received your appeal request.”

History of Special Enrollment Periods

The Patient Protection and Affordable Care Act (frequently shortened to the Affordable Care Act or ObamaCare) created the Special Enrollment Period (SEP) to allow eligible participants to purchase health insurance outside of open enrollment. The healthcare law adopted the special enrollment period qualifiers established by the Employee Retirement Income Security Act of 1974 and the Center for Medicare & Medicaid Services (CMS) and encourages the state-based marketplaces to “adopt similar special enrollment periods.” Generally, all states have done so, but differences do exist between states. 

In addition to the annual open enrollment periods and any special enrollment periods any individuals might qualify for, the Centers for Medicare and Medicaid Services (CMS) have extended or created unique one-time enrollment periods in the past.

The CMS announced February 20, 2015 that a special enrollment period for individuals and families would take place March 15, 2015 through April 30, 2015. The unique special enrollment period gave U.S. filers an extended chance to enroll in a health insurance plan that met the MEC requirements and avoid a penalty.

In a statement about the unique SEP, the CMS said it was for “those individuals and families who were unaware or didn’t understand the implications of this new requirement to enroll in 2015 health insurance coverage through the FFM.” Beginning in 2014, those who did not have some form of Minimum Essential Coverage (MEC) required by law were subject to a fee called the individual shared responsibility payment. The fee for not having coverage in 2014 was 1% of household income or $95 per adult and $47.50 per child under 18 years old up to $285. Those subject to the fee paid whichever was higher. 

Through June 30, 2015 there were just under 944,000 individuals who took advantage of a special enrollment period, including the unique period during the 2015 tax season.

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