What happens if you miss the Open Enrollment Period (OEP) to sign up for health insurance? Can you still get coverage? The answer is yes…with stipulations.
Those stipulations are largely dependent on an individual/family’s situation. There are particular events that will allow you to obtain coverage outside of the OEP, called qualifying life events (QLE) or special enrollment periods (SEP).
Generally, you are given 60 days prior to the event and/or 60 days from the day of the event to enroll into a new plan and that new plan will start the first of the following month in which you apply. Here are the most common QLEs and the details involved for each (please note, this is not a complete list of every qualifying event):
Changes in Household
Particular changes to a member of a household, like getting married, is considered a QLE where you can enroll in a new health insurance plan. Divorce or legal separation also allows for new enrollment into a plan outside of OEP, but there is a catch. The divorce/legal separation itself is not the QLE; it is loss of previous coverage due to the divorce/separation. You will have 60 days from the loss of coverage to enroll into a new plan.
The birth or adoption of a child is also considered a QLE and coverage can start on the day of the event. This being said, you are still given 60 days to enroll, and birth/adoption is the only QLE that will allow for a policy to be retroactively effective.
If someone that is currently enrolled in an ACA plan passes away, that will provide other members also enrolled in that plan 60 days to change plans.
Changes in Residence
Moving qualifies as a QLE, but only if you can show that you had prior coverage in place for one or more days during the 60 days before your move (does not apply for foreign country moves). Moving for medical treatment or vacation does not qualify. Moving to a new zip code/county, moving to the US from a foreign country or US territory, moving as a student from the place you attend school, or moving from a shelter or transitional housing are also QLEs for new coverage.
Loss of Health Coverage
Losing previous coverage for a number of reasons is the most common QLE. You can qualify for new coverage if you have lost or will lose prior coverage from various sources, most commonly when you lose employer-based coverage if there has been a separation of employment (being fired or leaving for new job). This event grants a 60-day window to enroll. However, voluntarily dropping coverage in favor of a different plan does not qualify as a QLE.
Aging off of a policy is also recognized as loss of coverage. Those turning 26 (the age limit for dependents on most policies) will qualify for a QLE.
Losing Medicaid or state-based coverage may also qualify you for new enrollment into a new policy. You can lose Medicaid due to a change in household size or household income. If a child ages off CHIP (Children’s Health Insurance Program) that qualifies as well. Another important topic with regards to Medicaid is if you are denied Medicaid and what that means. Even though you are not losing coverage, being denied Medicaid benefits through the state will qualify as a QLE.
If you are qualified for enrollment outside of OEP, you may be required to provide certain documentation to show proof of your QLE. That documentation is needed by Healthcare.gov within 30 to 60 days in order to effectuate the new policy. The documentation can be either uploaded online to the application or sent in via mail.
No matter your situation, ARC’s licensed health insurance agents are available to help you find coverage that works best for you. If you are qualified for a special enrollment period, give us a call and we can help you!