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13 Qualifying life events that trigger ACA special enrollment

By

Louise Norris

HealthInsurance.org

Published

Friday, June 28, 2024

Outside of ACA's annual open enrollment, you can still enroll or change plans if you experience a qualifying life event

Qualifying life events that trigger ACA special enrollment

Open enrollment for health insurance plans in the individual market (on- and off-exchange) runs from November 1 to January 15 in most states (some of the state-run exchanges have different deadlines).

But even outside of the annual open enrollment window, ACA-compliant plans can still be available to Americans who experience a qualifying life event.

(Note that the plans available outside of open enrollment without a qualifying life event are not regulated by the Affordable Care Act, and most are not a good choice to serve as stand-alone coverage. Short-term health insurance — which is available year-round and not regulated by the ACA — is intended to serve as stand-alone coverage for a short period of time, but it’s much less robust than ACA-compliant coverage.)

Qualifying life events that trigger ACA special enrollment

Outside of open enrollment, you can still enroll in a new plan if you have a qualifying life event that triggers your own special open enrollment (SEP) window.

People with employer-sponsored health insurance are used to both open enrollment windows and qualifying life events. In the employer group market, plans have annual open enrollment windows when members can make changes to their plans and eligible employees can enroll. Outside of that time frame, however, a qualifying life event is required to enroll or change coverage.

In the individual market, this was not how it worked before 2014 — people could apply for coverage anytime they wanted. But policies were not guaranteed issue in most states,1 so pre-existing conditions meant that some people couldn’t get coverage or had to pay more for their policies.

Qualifying life events that trigger ACA special enrollment
Outside of open enrollment, you can still enroll in a new plan if you have a qualifying life event that triggers your own special open enrollment (SEP) window.

People with employer-sponsored health insurance are used to both open enrollment windows and qualifying life events. In the employer group market, plans have annual open enrollment windows when members can make changes to their plans and eligible employees can enroll. Outside of that time frame, however, a qualifying life event is required to enroll or change coverage.

In the individual market, this was not how it worked before 2014 — people could apply for coverage anytime they wanted. But policies were not guaranteed issue in most states,1 so pre-existing conditions meant that some people couldn’t get coverage or had to pay more for their policies.

Got a qualifying life event? You may need to provide proof

HHS began ramping up enforcement of special enrollment period eligibility in 2016, amid concerns that enforcement had previously been too lax.

In February 2016, HHS confirmed that they would begin requiring proof of eligibility to grant special enrollment periods triggered by birth/adoption/placement for adoption, a permanent move, loss of other coverage, and marriage (together, these account for three-quarters of all qualifying life events in Healthcare.gov states). The eligibility verification process was further stepped up in 2017, thanks to “market stabilization” rules that HHS finalized in April 2017.

Starting in June 2017, HHS was planning to implement a pilot program to further enhance SEP eligibility verification (this plan was created by HHS under the Obama administration). Fifty percent of SEP enrollees were to be randomly selected for the pilot program, and their enrollments would be pended until their verification documents were submitted. They’d have 30 days to submit their proof of SEP eligibility, and as long as they did so, their policy would be effective as of the date determined by the date of their application/plan selection.

Under the new rules finalized in April 2017, however, that SEP eligibility verification process began to apply to 100% of SEP applications, starting in June 2017. By 2022, under the Biden administration, SEP eligibility verification had been scaled back slightly, and applied to 90% of special enrollment period applications. The SEP verification program has generated controversy, with some consumer advocates noting that it could further deter healthy people from enrolling when they’re eligible for a SEP. And HHS has noted that the verification process is harmful to Black applicants, as they are less likely to submit the necessary documentation than white consumers.

HHS addressed this in the annual rule-change notification for 2023. They removed the SEP verification requirements for all SEPs other than loss of coverage. Loss of coverage does represent the majority of SEP applications, and people using this SEP still have to provide proof of their loss of coverage. But pre-enrollment eligibility verification is no longer required on HealthCare.gov for other qualifying life events.

Understand, however, that state-run exchanges can set their own protocols, and insurers can still require proof of any qualifying life event for an off-exchange enrollment. In some state-run exchanges, the insurers conduct the SEP verification even on-exchange, and they can continue to do so (in Colorado, for example, all SEP verification is done by the insurers, and they require proof for 100% of SEP applications, on-exchange or off-exchange).

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