Guide to special enrollment periods

Not everyone who’s eligible to enroll in ACA-compliant health insurance bought coverage during the most recent open enrollment period.¹ Some people may have missed the annual enrollment deadline. Others may have decided that coverage was too expensive – perhaps unaware that they were eligible for premium subsidies if they enrolled on the Marketplace. Others may have felt they didn’t have enough information to make a decision.

But depending on the circumstances, many people can still enroll in ACA-compliant health coverage – even after the annual open enrollment period has ended – during a special enrollment period. There’s a lengthy list of qualifying life events that make consumers eligible for special enrollment, and this guide will walk you through all the qualifying life events and the specific rules for how they trigger special enrollment periods.

What is a special enrollment period?

Normally, ACA-compliant coverage is only available for purchase during the annual open enrollment period, but a special enrollment period allows people to sign up for coverage outside of that annual window. In most cases, this requires a qualifying life event.

In many cases, a special enrollment period is only available if an applicant already had minimum essential coverage prior to the qualifying life event. Other restrictions prevent people from using special enrollment periods (SEPs) to upgrade to better coverage during the year, though some of those restrictions have been relaxed in recent years.

During most SEPs, an individual (and dependents) can enroll in any health plan available in their Marketplace / exchange, although some SEPs limit current enrollees to a replacement plan at the same metal level as their current coverage. Most of the SEPs also apply to health plans available outside the exchange, giving people an option to pick off-exchange coverage if that’s their preference.

 How long are special enrollment periods?

Most of the qualifying life events trigger a special enrollment period that begins on the date of the qualifying life event and continues for 60 days. In most cases, the earliest that coverage can take effect is the first of the month after the special enrollment is completed.

However, in the case of involuntary loss of coverage, the special enrollment period begins in advance of the loss of coverage so that enrollees can purchase a new plan with no gap in coverage.

Qualifying life events that trigger special enrollment

• Involuntary loss of coverage that meets the definition of minimum essential coverage

• A permanent move to a place where different health insurance plans are available

• Divorce, death, or legal separation that results in the loss of coverage

• A change in eligibility for ACA premium subsidies or cost-sharing reductions

• A change in citizenship or lawful immigrant status

• Your employer-sponsored health insurance is unaffordable or stops providing minimum value

• Non-calendar renewal of your health plan

• A change in household income that causes the applicant to leave the Medicaid coverage gap

• A change in your household due to marriage, birth, adoption or foster care

• Exceptional circumstances, including natural disasters

• You’ve been offered a health reimbursement arrangement through your employer

• Your income doesn’t exceed 150% of the federal poverty level

Frequently asked questions about special enrollment periods and qualifying life events

• Why are special enrollment periods and qualifying life events necessary?

• Who doesn’t need a special enrollment period?

• What information will I need to prove my eligibility for a special enrollment period?