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

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

First days on the Exchanges

With the launch of the Health Insurance Exchanges on October 1st of 2013, there have a been a number of reports about millions of people unable to gain access to the exchanges.  Time out errors, computer glitches and all that fun computer stuff that makes our lives so much more fun.  The simple fact is enrollment began October 1st, but runs until March of next year, and no matter what, you coverage will be effective prior to January 01, 2014.  So why not take a breath, relax and wait 30 days until November and let the Exchanges work some of their bugs?    Even if you are one of the lucky ones to get logged in and shop for a plan during these early days, there already have been a number of reports of inaccurate quoting on the exchange will be even more frustrating come January when that first bill arrives in your mailbox.  Never mind the potential for computer threats to your personal data as well.  We suggest to take a step back, let the exchanges work out their “bugs” over the upcoming few weeks and then get online in a more stable environment.  This is definitely one of those times it will not pay to be one of the first.

Use Caution When Enrolling in Health Exchange Plans

Under the Affordable Care Act you will generally have 3 ways to in which to enroll in an Exchange Health Plan.

1) Through a Navigator,  or

2) Directly with the exchange, or

3) A licensed insurance agent who has certified with the exchanges to offer enrollment into the new ACA plans. and who may also help you compare to plans outside the Exchange for a complete side by side comparison.

Navigators have been enlisted namely by community organizations that have received funding grants through Affordable Care Act to help facilitate the enrollment into the Exchange’s Health Plans.  Navigators were required to take a minimum number of training hours to help them navigate the enrollment process.  Most are either volunteers or minimally paid to do so, few if any have an formal training with Insurance, are not licensed and have little oversight by regulatory authorities.   Some members of Congress recently expressed concern to Human Health Services, the agency overseeing the implementation of the ACA, that personal and confidential information provided to these Navigators may be extremely vulnerable to identity theft.  When enrolling in a health plan, applicants will need to provided extremely confidential data to enroll, and those assisting with the enrollment process will have access to this information.

By applying directly with the Exchanges, applicant will be able to apply themselves.   However, applying for all of the applicable benefits and credits may require several hours of study and many may find it confusing and inadvertently apply for the inappropriate coverage and subsidies.  Telephone assistance will be available through call centers which are neither licensed or experienced with health insurance in their respective states.

While many insurance agents and brokers have chosen not to participate with enrolling individuals in the ACA plans, some have.  Generally, most insurance brokers will have hundreds of hours of  training, and years of experience dealing with health insurance.  Many Insurance Professional will also be able to help consumers shop and compare plans both inside and outside of the exchanges.  There will be a number of competitive insurance plans offered outside of the Exchanges.  By contacting the Exchange directly or a Navigator, consumers will only be shown those plans inside the Exchange.  Further, a knowledgeable and experienced broker will be able to illustrate plans which may supplement coverage under a lower cost health plan while reducing your overall out of pocket exposure.  Insurance Agents and Brokers and licensed and strictly regulated by the State  Insurance Commissioners’ of their respective states.  Many may also carry Professional Errors and Omissions Insurance coverage to help protect you against their mistakes.

If you prefer to review a comprehensive comparison of plans both inside and outside the Exchanges, insure your confidential information is strictly safeguarded against identity theft, and receive help to make sure you apply for all the benefits you may be entitled to, not only from the ACA but from the other various federal and state assistance programs we suggest you submit a request for more information to be sure you receive all the benefits you are entitled to.






Special Enrollment Period for Marriage

An SEP exists for marriage. This means that, if a qualified individual gets married, he or she has the chance to either enroll in a QHP for the first time, or add a spouse to the plan without waiting for the annual open enrollment period.

If a marriage occurs and the Individual Marketplace is notified before the last day of the month when the marriage occurred, coverage will begin the 1st of the following month.
If a marriage occurs and the Individual Marketplace is notified after the end of the month when the marriage occurred, coverage will begin the 1st of the month following the notification.

The Individual Marketplace would need to be notified within 60 days of a marriage for a spouse to be covered. If the 60-day deadline is missed, the spouse cannot enroll until the plan’s annual open enrollment period.

Enrollment Periods

After their eligibility has been determined, individuals may enroll in a QHP during various timeframes throughout the year. The three timeframes are the initial open enrollment period, the annual open enrollment period, and special enrollment periods (SEP).

The initial open enrollment period begins October 1, 2013 (before the Marketplaces first make coverage available on January 1, 2014), and continues through March 31, 2014.
The annual open enrollment period is between October 15 and December 7 each year, beginning in 2014.
SEPs occur throughout the year, based on individuals’ special circumstances.

Beginning in 2014, the Marketplaces will send an annual open enrollment notice to each enrollee, between September 1 and September 30, to ensure enrollees are aware of the upcoming annual open enrollment period.

When Enrollment Selection is Received on October 15, 2014 to December 7, 2014 (or later year), Health Insurance Coverage Begins on January 1, 2015 (or later year).

When Enrollment Selection is Received on the 1st-15th calendar day of a given month, Health Insurance Coverage Begins on the 1st day of the following month.

When Enrollment Selection is Received on the 16th-31st calendar day of a given month, Health Insurance Coverage Begins on the 1st day of the second following month.
Note that Medicaid and CHIP do not limit the time periods during which an individual can enroll.