Individual Health Insurance Enrollment Periods Under the Affordable Care Act

The Open Enrollment to elect individual medical coverage in 2014 in the Health Insurance Marketplaces ended on March 31, 2014. This means that for the rest of the year, the only way an individual can elect coverage is if they qualify for a Special Enrollment Period (SEP).
A SEP includes, but is not limited to the following:

  • Gaining or becoming a dependent
  • Gaining status as a citizen, national, or lawfully present individual
  • Loss of minimum essential coverage (e.g., loss of Medicaid eligibility, termination of a Qualified Health Plan), except if enrollment is terminated based on failure to pay premiums
  • Loss of affordable employer-sponsored coverage
  • Determination that an individual is newly eligible or ineligible for premium tax credits or a change in eligibility for cost-sharing reductions
  • Permanent move to an area where different Qualified Health Plans are available
  • Other exceptional circumstances identified by the Marketplace

In most cases, SEPs will extend for 60 days from the date of the triggering event.These SEPs are based on certain triggering events or exceptional circumstances:

  • Under certain circumstances, such as the pending loss of minimum essential coverage due to the termination of a Qualified Health Plan, a Special Enrollment Period may begin before the triggering event takes place.
  • Under certain circumstances, individuals may change Qualified Health Plans outside of the annual open enrollment period.

The Centers for Medicare and Medicaid (CMS) have issued guidance on special enrollment periods for complex cases, and on the extension of the deadline for enrollment for consumers who are “in line” to sign up for coverage (see here).

Lastly, please note the following:

  • The next opportunity for individuals to enroll starts November 15, 2014 for a January 1, 2015 effective date
  • The next Open Enrollment Period begins November 15, 2014 and ends February 15, 2015
  • The enrollment timing will determine the effective date of coverage (e.g. enrolling by the 15th means you will be covered as of the 1st of the following month)
  • Individuals may otherwise enroll during a Special Enrollment Period

Any questions, please contact us.