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Small Business Employee Benefits and HR Blog

FAQ: What is a Special Enrollment Period?

A special enrollment period is a time when you’re allowed to make changes to your health insurance plan even though it’s not an open enrollment period.

special enrollment period

Special enrollment periods are standard with health insurance you get through an employer. Normally, you’re not allowed to sign up for health insurance or make any health plan changes except during the annual open enrollment period. However, certain qualifying events will trigger a special enrollment period allowing you to make changes for a certain period of time after the triggering event. If you don’t make the necessary changes to your health insurance during the special enrollment period, you’ll have to wait until the next open enrollment period to make any changes.

New Enrollment Periods for Guaranteed-Issue Individual Health Insurance

Starting in 2014, open enrollment periods and special enrollment periods will also apply to guaranteed-issue individual health insurance plans. That's because health insurers will be prohibited from denying individual health insurance coverage to people because of a pre-existing medical condition. 

The open enrollment periods ensure that individuals and families don’t wait until they get sick to enroll in coverage, or switch to more comprehensive coverage when they're about to have an expensive medical procedure.

Starting in 2014, consumers can only enroll in guaranteed-issue individual health insurance during specific open enrollment periods and special enrollment periods. This includes qualified health plans (QHPs) bought through the health insurance marketplaces and outside the marketplace.

Triggering Events for Special Enrollment Periods

Individuals and enrollees are able to enroll in a QHP or change from one plan to another outside the open enrollment period as a result of the following nine triggering events (also called 'qualifying events').

  1. A qualified individual or dependent loses minimum essential coverage

  2. A qualified individual gains a dependent or becomes a dependent through marriage, birth, adoption, or placement for adoption

  3. An individual, who was not previously a citizen, national, or law fully present individual gains such status

  4. A qualified individual’s enrollment or non-enrollment in a QHP is unintentional, inadvertent, or erroneous and is the result of the error, misrepresentation, or inaction of the Exchange or HHS

  5. An enrollee adequately demonstrates to the Exchange that the QHP in which he or she is enrolled substantially violated a material provision of its contract in relation to the enrollee 

  6. An individual is determined newly eligible or newly ineligible for advance payments of the premium tax credit or has a change in eligibility for cost-sharing reductions, regardless of whether such individual is already enrolled in a QHP. (The Exchange must permit individuals whose existing coverage through an eligible employer-sponsored plan will no longer be affordable or provide minimum value for his or her employer’s upcoming plan year to access this special enrollment period prior to the end of his or her coverage through such eligible employer-sponsored plan)

  7. A qualified individual or enrollee gains access to new QHPs as a result of a permanent move

  8. An Indian may enroll in a QHP or change from one to another one time per month

  9. A qualified individual or enrollee demonstrates to the Exchange that the individual meets other exceptional circumstances (as defined by the Exchange)

Unless specifically stated otherwise, an individual or enrollee has 60 days from the date of 
a triggering event to select a plan (source: exchange regulations).

Here's a chart summarizing the special enrollment period, and open enrollment periods for QHPs in 2014:

Enrollment Period: From:
Initial Open Enrollment (for coverage in 2014) October 1, 2013 to March 31, 2014
Annual Open Enrollment (for coverage in 2015, and beyond) November 15th to February 15th
Special Enrollment Period (after a qualifying event) Generally 60 days from qualifying life event

Do you have questions about a the special enrollment periods for individual health insurance? Leave a comment or question below.

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