Health Insurance

ACA Special Enrollment Period: What is it and How Does it Work?

ACA Special Enrollment Period: What is it and How Does it Work?

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Currently insured?

A special enrollment period is when you can join an Affordable Care Act (ACA) insurance plan outside regular open enrollment, which typically runs from Nov. 1 through Dec. 15.

To qualify for special enrollment, you must be experiencing a life event such as getting married or losing employer coverage. You generally need to select a health insurance marketplace plan within 60 days of your life event.

How do I qualify for a special enrollment period?

Several life changes allow for a special enrollment period. It's important to understand how and when you qualify, enroll and apply. If you supply all the needed information before the deadline, you typically can avoid a gap in coverage and the potential for costly medical bills.

Events that allow for a special enrollment period fall into six main groups:

Not all special enrollment periods require paperwork to prove that you're eligible. You will learn during the application process whether you need to send documents, but where possible we've listed records you may be asked to provide.

With most special enrollment periods, you must apply within 60 days of a qualifying life event. Coverage generally starts the first of the month after choosing a marketplace plan, as long as you've paid the premium.

Your family makeup changes

This special enrollment period applies when you need to add new family members to your plan or you lose coverage due to a death or divorce. When you have a baby or adopt or foster a child, you can retroactively begin coverage the day of the event, so long as you enroll within 60 days afterward.

Life event
Documentation requirements
Getting marriedProvide a marriage certificate or license showing the spouses' names and the date of marriage
Having a baby, adopting a child or placing a child for foster careFor adoption or a foster care placement, supply adoption letters or records, court orders or foster care papers
Divorce or legal separation causing a loss of health insuranceThe divorce or separation must result in loss of coverage
Losing coverage due to a deathOccurs when you lose eligibility for your current marketplace plan due to the death of someone on that plan

You move to the U.S. or relocate within the U.S.

Several moving scenarios qualify you for a special enrollment period — even moving to a new ZIP code or county is enough justification to select a new health plan.

If you moved within the U.S., you must provide proof that you relocated in the last 60 days and that you had health coverage for at least one day during the 60 days before your move.

If you moved to the U.S. from a foreign country you must show proof of your move, but you don't need to verify prior health coverage.

These moves qualify for this special enrollment period:

  • Moving to a new home in a new ZIP code or county
  • Moving to the U.S. from a foreign country or a United States territory
  • If you're a student, moving to or from the place you attend school
  • If you're a seasonal worker, moving to or from the place you both live and work
  • Moving to or from a shelter or other transitional housing

You lose other health insurance

When you apply for a special enrollment period because of losing your insurance, you must pick a plan through the Health Insurance Marketplace within 60 days before or after the date you lose coverage. Once you choose a plan, you have 30 days to supply documents showing when your plan expired.

Life event
Requirements or triggering events
Losing job-based or family coverage
  • You lose health coverage through your employer or the employer of a family member, including if you lose coverage because you're no longer a dependent
  • You lose coverage when something unexpected happens with a family marketplace insurance plan
Losing an individual health policy you bought yourself
  • Your marketplace plan is discontinued
  • You lose eligibility for a student health plan
  • Your household income decreases and you qualify for savings on a marketplace plan
Losing eligibility for Medicaid or Children's Health Insurance Program (CHIP) coverage
  • Your income changes
  • Your child ages out of CHIP
Losing eligibility for MedicareYou become ineligible for premium-free Medicare Part A ?
Losing COBRA coverage
  • Your COBRA plan runs out or your former employer stops contributing
  • You don't qualify if you drop COBRA on your own or fail to pay your premium

You experience other life changes

You may qualify for a special enrollment period if you encounter other life changes such as becoming a U.S. citizen or leaving a correctional facility. You must apply within 60 days of the event and may need to send proof of your eligibility.

Life event
Required documents
Gaining membership in a federally recognized tribe or status as an Alaska Native Claims Settlement Act (ANCSA) shareholder
  • You must send one of three items:
    • A document issued by a federally recognized tribe indicating tribal membership
    • A document issued by an Alaska Native village or tribe
    • An ANCSA Corporation (regional or village) document indicating shareholder status
Becoming a U.S. citizen
  • You must apply within 60 days from the date you became a citizen or a lawfully present resident
  • You need to provide a U.S. passport, Certificate of Naturalization or Certificate of Citizenship
Leaving incarceration
  • You must apply within 60 days from your release date
  • Official release or parole papers, an unexpired ID card or pay stubs will be required
Starting or ending service as an AmeriCorps, VISTA or NCCC member
  • You must apply within 60 days from the date you begin or end your service in one of these agencies

You encounter another less-common scenario

You may qualify for a special enrollment period in complex situations that prevent or delay you from applying during an open enrollment period. For example, you may have encountered a natural disaster or had technical issues with the HealthCare.gov website.

Life event
What to know
Exceptional circumstances
  • An issue kept you from applying during open enrollment such as hospitalization, temporary cognitive disability or a natural disaster
  • For a natural disaster, you must live in a county that is eligible to apply for assistance by the Federal Emergency Management Agency (FEMA)
Enrollment, plan information or display errors
  • You had issues with the HealthCare.gov site including wrong plan data or an error message that kept your enrollment application from going through
  • An official engaged in misconduct that kept you from enrolling or qualifying for cost savings
Being denied enrollment in Medicaid or CHIP
  • You applied for Medicaid or CHIP during a marketplace open enrollment period (usually between Nov. 1 and Dec. 15 of each year) and got your denial notice after the marketplace open enrollment ends
  • You need to provide a copy of the Medicaid or CHIP denial letter
You experienced domestic abuse or violence or spousal abandonment
  • You and your dependents may qualify if you're a survivor of domestic abuse or violence or spousal abandonment and you want to enroll in your own separate health plan
  • You can enroll by contacting the Health Insurance Marketplace call center
You are denied coverage, file an appeal and are then approved for enrollment
  • If you filed an appeal and were successful, you can change your ACA plan or enroll in a new policy

Your employer-sponsored insurance becomes too costly or no longer provides minimum coverage

You qualify for this special enrollment if your premium is more than 9.61% of your household income or the plan pays less than 60% of covered medical costs (meaning it's not providing minimum coverage). You also must be otherwise eligible for subsidies in the exchange based on your income.

The premium requirement refers only to the portion of employer coverage you pay for yourself, not what you pay for your family members.


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Currently insured?

How do I apply for a special enrollment period?

You apply for coverage during a special enrollment period much like you would during open enrollment. To start the process, create an online account through a health insurance marketplace When you apply for special enrollment, you must provide the specific reason you qualify. HealthCare.gov will review your application and let you know whether you need to send documents to prove your eligibility.

If your qualifying event happens to occur during open enrollment, you can apply during that period without the need to submit proof of your status. Open enrollment dates don't often change, but be sure to apply within the deadline for the upcoming calendar year.

When should I apply?

You typically have 60 days after a qualifying event to apply for coverage. In some cases, you can apply up to 60 days before an expected event occurs, such as losing health insurance when you quit your job. Submitting your application within the required time limit helps to avoid gaps in your health care coverage. After you pick a plan, you have 30 days to send any required documents.

Is any documentation required?

After submitting your application, you'll receive an eligibility notice letting you know whether documents are needed and when you must send them. If your eligibility notice doesn't say you must submit any records, then you don't need to do so.

If your eligibility notice includes a request for documents, send them as soon as possible after you pick a plan to prevent a delay in coverage. The quickest method is to upload the documents to your HealthCare.gov account. You also can mail copies to:

  • Health Insurance Marketplace
  • Attn: Supporting Documentation
  • 465 Industrial Blvd.
  • London, KY 40750-0001

What happens after I apply?

If your request is approved, HealthCare.gov will send a confirmation to the insurance plan you choose. Your coverage won’t start until you pay your first premium, so send that payment as soon as you can.

Your coverage start date is normally the first of the month after you pick a plan and are approved. But you can’t use your coverage until you're approved and you make your first payment.

If HealthCare.gov can't confirm your special enrollment period using the documents you provide, the agency will send you a letter of explanation or add a notice to your marketplace account. You can upload the needed documents or let HealthCare.gov know in writing why you can't provide them.

What do I do if my special enrollment request is denied?

If you think your special enrollment period was denied in error, you can file an appeal. If your enrollment is approved based on the appeal, you can get coverage back to the date your special enrollment period was first denied.

To file an appeal, select your state’s form from the HealthCare.gov appeals page.

You can either complete and submit the form online or fill out a printed version and mail it to:

  • Health Insurance Marketplace
  • Attn: Appeals
  • 465 Industrial Blvd.
  • London, KY 40750-0061

Although not required, you can attach a copy of the eligibility denial or other official notice you received to help with processing.

Frequently asked questions

How long is the ACA special enrollment period?

Most special enrollment periods last 60 days. You must apply for a plan through a state or federal marketplace within 60 days of experiencing a life event. With some special enrollment periods, such as losing health coverage on your 26th birthday, you can start the process up to 60 days before the date your event will occur.

What happens if I miss the special enrollment period?

If you missed a special enrollment period and don't qualify for another one, check income-based plans like Medicaid and CHIP, which you can apply for at any time. Otherwise, you'll need to wait for the next open enrollment period to sign up for a marketplace health plan.

Is there a special enrollment period for Medicaid or CHIP?

There is no special enrollment period for Medicaid or CHIP — you can apply for either program at any time of year. If you need health coverage and think you might be eligible, you should apply as soon as possible. To qualify, you need to meet income or health-related requirements set by your state or the federal government.

What is the difference between open enrollment and special enrollment?

Open enrollment is the annual period when you sign up for ACA health insurance or change your existing plan. It's available to anyone and usually runs from Nov. 1 to Dec. 15 of each year. Special enrollment allows you to sign up for health insurance at any time of year, but you must qualify based on a specific life event.

Methodology

Information on special enrollment options, eligibility and application requirements was obtained directly from CMS.gov and HealthCare.gov. Medicaid and CHIP information also was sourced from HealthCare.gov.

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