Before the bulk of the Affordable Care Act’s (ACA) provisions took effect in 2014,1health insurance carriers in the individual major medical coverage market accepted applications all year round. But not all of those applications were approved.
Applications from people with significant pre-existing health conditions could be rejected altogether in all but five states.2 And even people with relatively minor pre-existing conditions often found that they were only able to get a policy that either excluded their pre-existing conditions or charged them higher premiums as a result of their medical history.3
That all changed in 2014. Applicants in the individual/family major medical coverage market can no longer be rejected or charged a higher premium because of pre-existing conditions. Applications for individual/family coverage, whether on- or off-exchange, don’t even ask questions about medical history anymore, because medical underwriting is no longer used in the individual major medical market. (Note that this doesn’t apply to plans that aren’t regulated by the ACA, like short-term health insurance plans.)
Why the need for a limited open enrollment period?
Since coverage is now guaranteed issue regardless of medical history, the trade-off is that enrollment is limited to an annual open enrollment period and special enrollment periods triggered by qualifying life events.4 It’s easy to see why this is necessary: if enrollment were available year-round without any limitations on coverage for pre-existing conditions, the insurance market would likely become unstable. (Washington state was an example of this in the 1990s; the state began requiring guaranteed issue coverage in the individual market, but did not implement limited enrollment periods or requirements that people maintain coverage, and the result was a collapse of the individual insurance market in the state.)
People would be able to wait to enroll until they were in need of healthcare, and skip paying premiums the rest of the time, resulting in adverse selection. From 2014 through 2018, the ACA’s penalty for being uninsured applied in situations where people skipped coverage altogether, but in 2015 at least the cost of coverage was typically more than the cost of the penalty, and the IRS had few tools available to enforce collection of the penalty. And the federal penalty no longer applies – it was repealed as of January 2019 by the GOP tax bill that was enacted in late 2017. Some states have their own individual mandates and penalties for non-compliance.5
In short, it wouldn’t be sustainable to allow year-round enrollment in plans that are guaranteed issue regardless of medical history. That could result in higher premiums, fewer enrollees, and eventual market collapse.
So when the ACA was written, it included a provision to limit enrollment to an annual open enrollment period, similar to the model that was already used for Medicare and employer-sponsored health coverage. The specifics in terms of the dates and length of open enrollment have changed several times over the last few years. Beginning in 2022, HHS implemented an extended enrollment window that continues through January 15 each year, instead of ending in mid-December as it did for several previous years. (Some state-run exchanges have different enrollment windows).
Once open enrollment ends for the year, enrollment is closed in the individual market, on and off the exchange.
Qualifying life events – because ‘life happens.’
That is, unless you have a qualifying life event. When the ACA was written, lawmakers understood the importance of limiting enrollment to specific times of the year if coverage was to be guaranteed-issue.6 But they also understood that some life-changing events warrant an opportunity outside annual enrollment to enroll in a new health plan.7
Life happens. Babies are born, other coverage ends, people move. It wouldn’t make sense to force people to wait until the following January to change to coverage more useful in their new location under a new plan following a cross-country move, or to enroll their newborn in a health plan.
The model for qualifying life events and special enrollment periods already existed in other markets, including Medicare Advantage, Medicare Part D, and employer-sponsored insurance. If you’ve previously had employer-sponsored health insurance, you’re used to the idea that you’ve got an annual enrollment period, and you can only make changes outside of that period if you have extenuating circumstances – a qualifying life event. (The specific qualifying life events that trigger a special enrollment period for employer-sponsored coverage are outlined here, and are not entirely the same as qualifying life events for individual market coverage.)
That was an entirely new concept in the individual health insurance market in 2014,8 but people have since become used to it. You may be asked to provide proof of your qualifying life event when you apply for coverage. If so, the Marketplace or insurer will let you know what documentation you need to submit.
And understand that in many cases, you’ll need to have had minimum essential coverage in place before the qualifying life event in order to have a special enrollment period.9 In other words, some of the most commonly used qualifying life events, including loss of other coverage, marriage, and moving to a new area, allow for a person to change from one health plan to another, with no more than a short break between plans, as opposed to enrolling in coverage without having had a previous minimum essential coverage in place. There are also limitations in many cases that prevent people from changing to a plan at a different metal level during a special enrollment period.
If you do experience a qualifying life event and meet the other applicable eligibility rules (not being enrolled in Medicare, and for the Marketplace, this also means being lawfully present in the US and not incarcerated), you’ll have access to a special enrollment period, regardless of when it happens during the year. Most qualifying life events trigger special enrollment periods both on and off the exchanges, and special enrollment periods generally last for 60 days, although some last for 60 days both before and after the qualifying life event.
And if someone in your tax household (the people listed on your tax return) qualifies for a special enrollment period, everyone in the tax household can enroll using that special enrollment period. This was already clarified in previous regulations, but HHS has proposed a technical correction to ensure that the language around this isn’t ambiguous.
The idea of qualifying life events and special enrollment periods is not new, and some of the ACA individual market’s qualifying life events overlap with qualifying life events that apply in the Medicare market and employer-sponsored insurance. But some qualifying life events are specific to the individual market.
This guide will walk you through all of the ACA’s qualifying life events and associated special enrollment periods. If you’re uncertain about your eligibility for a special enrollment period, you can contact a navigator, certified applicant counselor, or insurance producer about your circumstances.
Louise Norris is an individual health insurance broker who has been writing about health insurance and health reform since 2006. She has written dozens of opinions and educational pieces about the Affordable Care Act for healthinsurance.org.
Footnotes
- “The Patient Protection and Affordable Care Act: Implications for Public Health Policy and Practice – PMC” Accessed March 4, 2024 ⤶
- “Pre-Existing Condition Prevalence for Individuals and Families” KFF.org, Oct. 4, 2019 ⤶
- “At Risk: Pre-Existing Conditions Could Affect 1 in 2 Americans” HHS.gov, Accessed March 4, 2024 ⤶
- “Overview: Final Rule for Health Insurance Market Reforms” CMS.gov, Accessed March 4, 2024 ⤶
- “I’m uninsured. Am I required to get health insurance?” KFF.org. Accessed March 4, 2024 ⤶
- “Blue Cross Blue Shield Ass’n Amicus Brief.pdf” oag.ca.gov, Accessed March 5, 2024 ⤶
- “Compilation of Patient Protection and Affordable Care Act” housedocs.house.gov. June 9, 2010 ⤶
- “Medicaid, Children’s Health Insurance Programs, and Exchanges: Essential Health Benefits in Alternative Benefit Plans, Eligibility Notices, Fair Hearing and Appeal Processes for Medicaid and Exchange Eligibility Appeals and Other Provisions Related to Eli” Federal Register. Accessed March 5, 2024 ⤶
- “§ 155.420 Special enrollment periods.” eCFR.gov, Accessed March 5, 2024 ⤶
