Special Enrollment Periods for Individual Health Insurance


Individual medical health insurance (also generally known as individual/family medical health insurance) is the sort that you simply buy yourself as a substitute of obtaining from an employer. There’s an annual window every year—in most states, from November 1 to January 15—when enrollment is open to buy these plans.

Outside of that window, special enrollment periods allow people to purchase individual medical health insurance or switch to a special plan once they experience certain circumstances or life events.

The foundations for individual medical health insurance special enrollment periods stem from the Reasonably priced Care Act (ACA) and subsequent regulations. They’re unique to the person market and the principles usually are not the identical for employer-sponsored plans. This text will explain how special enrollment periods work for individuals who buy their very own medical health insurance.

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What Is a Special Enrollment Period?

A special enrollment period is a window during which an individual can enroll in health coverage or switch to a special plan outside of the traditional annual open enrollment period.

In the person market, special enrollment periods generally run for 60 days following a qualifying life event, although some extend for 60 days before and after the event. Some special enrollment periods allow people to enroll in or switch to any available health plan, whereas others are more limited.

Most individual medical health insurance special enrollment periods require a qualifying life event. But some are simply available to a selected population (comparable to Native Americans or certain applicants with low income) with no specific life event.

Most special enrollment periods also require that the person have minimum essential coverage before the qualifying life event. In other words, most special enrollment periods are inclined to be a chance to vary coverage somewhat than a chance to newly enroll in coverage—but there are some exceptions.

Why Are Special Enrollment Periods Essential?

Prior to 2014, individual medical health insurance might be purchased year-round. But in nearly every state it was also subject to medical underwriting. This meant that the medical health insurance company would take a look at the applicant’s medical history when deciding whether to supply them a policy (and if that’s the case, how much to charge for it and whether to exclude any preexisting conditions, that are medical conditions that they had before enrolling).

The Reasonably priced Care Act modified all of that. Under the ACA, individual medical health insurance is guaranteed issue, which suggests insurers can not consider an applicant’s medical history.

However the flip side is that coverage isn’t any longer available year-round. As a substitute, it now follows the identical type of rules that had long been used for employer-sponsored coverage: You possibly can only enroll during open enrollment or during a special enrollment period.

Without limited enrollment windows, people could simply wait until they need medical care after which buy coverage, potentially causing a death spiral (premiums rapidly increase on account of changes within the covered population) within the insurance market.

How Are Special Enrollment Periods Regulated?

The federal government has created regulations (detailed within the Code of Federal Regulations, in 45 CFR § 155.420) that pertain to special enrollment periods for individual medical health insurance. Note that these usually are not the identical rules that apply to special enrollment periods for employer-sponsored medical health insurance (those are detailed within the Code of Federal Regulations, 29 CFR § 2590.701-6).

The person market includes plans purchased through the medical health insurance exchange in addition to plans purchased directly from a medical health insurance company (also generally known as “off-exchange” plans). Most special enrollment periods apply each on-exchange and off-exchange, although there are some which are only available on-exchange.

The federal rules for special enrollment periods apply in every state that uses the federally run exchange (HealthCare.gov). And plenty of of them also should be offered in states that run their very own exchanges.

But some federally created special enrollment periods are optional for state-run exchanges. And a few state-run exchanges go above and beyond the federal rules, offering additional special enrollment opportunities for his or her residents.

So, to some extent, special enrollment periods for individual medical health insurance do vary a bit from one state to a different.

Qualifying Life Events

There may be a protracted list of qualifying events that can create a special enrollment period for ACA-compliant individual medical health insurance. They include:

Involuntary lack of other minimum essential coverage: Involuntary loss implies that the person didn’t cancel the plan themselves, fail to pay the premiums, or lose the coverage in consequence of rescission (termination on account of fraud or misrepresentation).

But lack of employer-sponsored coverage does count as involuntary lack of coverage, even when the person voluntarily left their job or reduced their hours enough to not qualify for coverage. And the special enrollment period is on the market no matter whether an individual is eligible for Consolidated Omnibus Budget Reconciliation Act (COBRA) medical health insurance (insurance plan that an worker continues paying premiums on and whose advantages carry over after that person leaves the job).

Lack of coverage that isn’t minimum essential coverage, comparable to a short-term health plan (temporary coverage once you experience a lapse in everlasting coverage) or healthcare sharing ministry plan (healthcare plan with shared costs amongst members who share religious or ethical beliefs), doesn’t lead to a special enrollment period.

Marriage: Most often, at the least one spouse should have had minimum essential coverage prior to the wedding with the intention to trigger a special enrollment period.

Gaining or becoming a dependent: This might be by birth or adoption, and it also applies when a toddler support order is issued.

A everlasting move to a location where different health plans can be found: Most often, there may be a requirement that the person already had minimum essential coverage prior to the move.

Individual health plans are regulated and sold on the state level, so a move to a special state will trigger a special enrollment period. But when different health plans are sold in several parts of a state (which is usually the case) a move inside the state can create a special enrollment period.

A change in subsidy eligibility: The ACA provides income-based premium subsidies and cost-sharing reductions for individuals who enroll in health coverage through the exchange.

Depending on the circumstances, an individual might be eligible for a special enrollment period, allowing them to modify to a special plan in the event that they experience an income change that makes them newly eligible or newly ineligible for either kind of financial assistance.

A one who is within the “coverage gap” in a state that hasn’t expanded Medicaid (state-sponsored medical health insurance) will qualify for a special enrollment period if their income increases to above the poverty level.

Becoming a U.S. citizen or lawfully present resident: It’s also essential to notice that lawfully present immigrants can qualify for subsidies within the exchange, even with income below the poverty level. Citizenship is just not required for subsidy eligibility.

Certain changes to employer-sponsored coverage: In case your employer-sponsored health plan (or your circumstances, including your income) change and the result’s that your employer-sponsored health plan isn’t any longer considered inexpensive or not provides minimum value, you’ll qualify for a special enrollment period, during which you’ll be able to switch to individual medical health insurance should you decide to accomplish that.

Having access to a QSEHRA or ICHRA: In the event you turn into eligible for employer reimbursement of individual medical health insurance premiums, either via a certified small employer health reimbursement arrangement (QSEHRA) or individual coverage health reimbursement arrangement (ICHRA), you’ll qualify for a special enrollment period, during which you’ll be able to join for individual medical health insurance.

Your health plan renews sometime apart from January 1: In the event you’re enrolled in an employer-sponsored plan that renews midyear or a person market plan that renews midyear—including grandmothered plans (in place since before January 1, 2014) or grandfathered plans (in place on March 23, 2010, when the ACA was signed into law—you’ll be able to decide to drop that coverage (as a substitute of renewing it) and use a special enrollment period to modify to an ACA-compliant individual market health plan.

(Note that should you’re eligible for employer-sponsored coverage that’s considered inexpensive and that gives minimum value, you wouldn’t be eligible for any subsidies within the exchange should you select to modify to a person market plan.)

Exceptional circumstances: It is a catch-all category that may include things like natural disasters that prevented an individual from enrolling during open enrollment, or errors made by the exchange or the health plan.

Some state-run medical health insurance exchanges use this category to permit a special enrollment period on account of pregnancy. Others use it to create a special enrollment period for individuals who utilize the state tax return process to find out their eligibility for health coverage advantages.


Because the person medical health insurance market not uses medical underwriting (coverage is guaranteed issue, no matter medical history), enrollment is restricted to an annual open enrollment period.

But certain qualifying life events—comparable to lack of other coverage, marriage, or moving to a latest area—will allow an individual to enroll in individual market coverage outside of the annual open enrollment period.

A Word From Verywell

If you might want to purchase medical health insurance outside of the annual open enrollment period, check to see should you’re eligible for a special enrollment period. In the event you are, you’ll generally have at the least 60 days to submit an application and choose a plan.

Most often, you’ll be able to do that through the exchange or directly through an insurance company. But be mindful that financial assistance is just available through the exchange. Most persons are eligible for financial assistance, so it’s likely in your best interest to hunt coverage within the exchange during your special enrollment period.

Continuously Asked Questions

  • Why do we’d like special enrollment periods in the person market?

    Without special enrollment periods, people would should wait until the annual open enrollment period to join self-purchased coverage.

    With special enrollment periods, a qualifying life event—comparable to lack of other coverage or the birth of a baby—will allow people to keep up seamless coverage, without having to attend until the following yr to get a latest health plan.

  • When will my coverage renew if I exploit a special enrollment period?

    In the event you enroll midyear using a special enrollment period, your health plan will still follow the identical calendar-year schedule that’s used for all ACA-compliant individual market plans.

    So for instance, in case your special enrollment period permits you to enroll in a plan with an October 1 effective date, it should still have a plan yr that ends December 31. You’ll start over with a latest plan yr just just a few months after your coverage took effect.


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