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Insider’s Guide to Obamacare’s Special Enrollment Periods

What millions of consumers don't know about qualifying life events can't help them capitalize on the Affordable Care Act's special enrollment periods

Publication of the first edition of healthinsurance.org’s Guide to Obamacare’s Open Enrollment in 2014 was our response to readers’ frequent requests for information about their enrollment options under the Affordable Care Act.

Our guide has helped thousands of readers successfully navigate the Affordable Care Act’s annual open enrollment period and find affordable, quality health insurance – either through the health marketplaces or off-exchange. We’re proud to have been part of the decrease in the national uninsured rate.

We do know, of course, that not everyone eligible for ACA-compliant health coverage bought coverage during the most recent open enrollment period. Some folks may not have enrolled because they somehow missed the enrollment deadlines. Others may have thought coverage was too expensive, or weren’t aware that they were eligible for the ACA’s premium subsidies (which are substantial enough that 6 million uninsured Americans can qualify for free health insurance, due in part to the American Rescue Plan’s enhancement of the ACA’s subsidies). Others simply didn’t have enough information to make a decision.

But depending on the circumstances, people can still enroll in health coverage even after open enrollment has ended, if they experience a qualifying event. This guide will walk you through all the qualifying events and the specific rules for how they trigger special enrollment periods.

Special enrollment periods are normally required in order to buy coverage outside of open enrollment

In a normal year, enrollment outside of the open enrollment window is only available if you experience a qualifying event. It doesn’t matter how healthy you are, or whether you’ve had continuous coverage or how much you’re able to pay – enrollment is simply not available for most of the year without a qualifying event.

And that’s where our Insider’s Guide to Special Enrollment comes in.

Louise Norris, a highly regarded expert on health insurance and author of our first guide, has put together an authoritative overview of special enrollment periods and the qualifying events that trigger those SEPs. [Note that this guide is specific to special enrollment periods in the individual market; the special enrollment period rules that apply to employer-sponsored plans are similar, but not entirely the same.]

During most SEPs, an individual (and dependents) can enroll in any health plan available in the exchange (as discussed later in this guide, some SEPs have restrictions for plan changes that limit people to a plan at the same metal level they already have). And most of the SEPs also apply to health plans available outside the exchange.

As a licensed agent, the author has seen them all – obvious triggers like loss of coverage due to divorce or legal separation, and not-so-obvious triggers such as an increase in income that makes someone newly eligible or newly ineligible for exchange subsidies.

The qualifying events that trigger special enrollment periods in 2022 are mostly the same as they were in 2020 and 2021, although there have been some additional SEPs added (for example, situations involving employer reimbursement of health insurance premiums, people who have off-exchange coverage and then experience an income change that makes them newly eligible for premium subsidies in the exchange, and people with income below 150% of the poverty level). And as has been the case in the past few years, you’ll generally need to be prepared to provide proof of your qualifying event.

In most cases, a special enrollment period is only available if you already had minimum essential coverage before the qualifying event, and there are restrictions that prevent people from using SEPs to upgrade to better coverage during the year. Some of these restrictions and nuances have been added over the years, so the rules aren’t the same as they were in the beginning.

If you’re reading this guide and feel paralyzed in the “off-season” – the 9.5 months outside of open enrollment – don’t despair. It’s possible you already have a qualifying life event. And if you don’t right now, there may be one just around the next corner. If you’re uncertain about your eligibility for a special enrollment period, call (866) 686-8071 to discuss your situation with a licensed insurance professional.

We hope you find this guide useful – and if you do – we hope you’ll share it with someone else who needs the information.

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Table of Contents

Insider’s Guide to Obamacare’s Special Enrollment Periods
1 Qualifying events and why we need them
2 Who doesn’t need a special enrollment period?
3 Involuntary loss of coverage is a qualifying event
4 How your ‘big move’ can trigger an SEP
5 Divorce, death, or legal separation: SEP is optional
6 A change in subsidy eligibility changes your options
7 Citizenship or lawful immigrant status can deliver coverage
8 An SEP if your employer plan doesn’t measure up
9 Non-calendar-year renewal as a qualifying event
10 Leaving the coverage gap? This SEP’s for you.
11 Proving you deserve a special enrollment period
12 An SEP for your growing family
13 Exceptional circumstances for special enrollment
14 An SEP if you have a QSEHRA or ICHRA
15 An SEP if your income doesn’t exceed 150% of the federal poverty level

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