Open Enrollment Period vs. Special Enrollment Period

One very significant change to the individual health insurance market made by the Affordable Care Act (ACA) is the implementation of open enrollment (OEP) and special enrollment periods (SEP).

Prior to the ACA, an individual could purchase health insurance from an insurance carrier any time but the insurance carrier could reject an application or increase the rates, based on a pre-existing condition of the applicant.

The ACA no longer allows insurance carriers to deny applications based on pre-existing conditions, so without a stricter enrollment period, consumers could simply wait until they were stricken with a severe condition to purchase health insurance. This is referred to as “adverse selection” and defined open enrollment periods attempt to limit such negative risk for insurance carriers.

The first ACA open enrollment period began on October 1, 2013, and ended March 31, 2014. The next open enrollment period will run from November 15, 2014, to February 15, 2015, for health plans with effective dates in 2015. So, generally, if you did not purchase insurance by March 31, 2014, you will have to remain uninsured until 2015, unless you have a qualifying event, in which case you will be eligible to enroll during an SEP.

SEPs exist to allow certain people to enroll outside of the regular open enrollment period, if they have an event that leaves them without health insurance coverage.

Qualifying Events

Examples of qualifying events and their effective dates are:

Example 1 Qualifying Events:  Loss of employer group health insurance, as a result of termination of employment (voluntary or involuntary), change in full-time employment status, or termination of employer contributions; exhaustion of COBRA or state continuation; loss of dependent status as a result of turning 26

Effective Date:  1st day of the month following the receipt of the application

Example 2 Qualifying Event:  Marriage

Effective Date:  1st day of the month following the receipt of the application

Example 3 Qualifying Event:  New dependent (birth, adoption, placement for adoption)

Effective Date:  Date of event for the child; for parent(s) and other dependents applying with the parent(s), the effective date is based on the application received date.  Those applications received from the 1st through 15th of the month are effective the 1st of following month and those received from the 16th through end of the month are effective the 1st of 2nd following month.

Example 4 Qualifying Events:  Employer Coverage is no longer affordable (as determined by the Marketplace/Exchange) or no longer provides Minimum Essential Coverage (MEC)

Effective Date:  Applications received between the 1st through 15th are effective the 1st of following month and those received from the 16th through end of the month are effective the 1st of 2nd following month

Frequently Asked Questions

If I have a qualifying event, how long do I have to enroll in a new plan? Generally, you have 60 days from the date the qualifying event happens to enroll in a health plan.

Do I need to submit proof of the qualifying event? Yes. Be prepared to include a note from your employer, cancelled health insurance notice, marriage license, divorce decree, birth certificate, etc. with your application.

Can an agent help me with the Special Enrollment Period? Yes. Contact a Caravus Individual Market consultant to determine whether you qualify for a Special Enrollment Period.