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FAQs: Open & Special Enrollment Periods for Health Insurance

Written by Andrew Le, MD

UpdatedOctober 13, 2024

Getting health insurance can be confusing, especially when it comes to knowing when you're eligible to enroll or make changes to your plan. Many people miss out on key dates for open enrollment or special enrollment periods, which can lead to missed opportunities to secure or update coverage.

This confusion often causes delays or gaps in coverage, leaving many without insurance during critical moments.

This article will answer common questions about open and special enrollment periods for health insurance. Whether you're unsure of the dates or need clarification on qualifying life events for special enrollment, we'll break down the process to help you stay informed and covered.

1. What is the Open Enrollment Period (OEP)?

The OEP is a designated time frame each year during which you can enroll in a health insurance plan or change your existing coverage. Several types of insurance plans have open enrollment periods, including:

  • Health Insurance (ACA Marketplace)
  • Medicare
  • Employer-Sponsored Health Insurance

A. OEP for ACA Marketplace Plans

The Marketplace enrollment opens on November 1 and ends on December 15. Signing up during this window allows your coverage to begin as early as January 1 of the following year. A second period, from December 16 to January 15, offers another chance to enroll or update your plan, with coverage starting on February 1.

To enroll in a plan through the Marketplace, you must:

  1. Be a US citizen or lawfully present in the US.
  2. Not currently incarcerated.
  3. Live in the United States.
  4. Not have Medicare coverage.

B. OEP for Medicare

The Medicare OEP runs from October 15 to December 7. During this time, you can review Medicare plans available in your area and make changes to your coverage, with any updates taking effect on January 1 of the following year.

You can enroll in Medicare if you meet one of the following criteria

  • Age 65 or older
  • Under 65 with certain disabilities
  • Any age with End-Stage Renal Disease (ESRD)
  • Any age with Amyotrophic Lateral Sclerosis (ALS)

C. OEP for Employer-Sponsored Health Insurance

For employer-sponsored insurance, the OEP depends on your employer and can take place at any point during the year. Some employers hold open enrollment in the fall, allowing coverage to begin on January 1.

Others may align it with the start of their fiscal year, which may not follow the calendar year. If you're uncertain about the open enrollment schedule for your workplace, be sure to contact your employer for clarification.

2. What happens if I miss the Open Enrollment Period?

If you miss the OEP, your options for obtaining health insurance are significantly limited.

Generally, you won’t be able to enroll in or change your health insurance plan until the next OEP unless you qualify for a Special Enrollment Period (SEP).

Consequences of missing the OEP:

  • You may have to go without health insurance until the next OEP, potentially leaving you exposed to high medical costs.
  • Even if you find a plan outside the OEP, it might not cover pre-existing conditions, and the premiums could be higher.

3. What is the Special Enrollment Period (SEP)?

This period lets you enroll in or make changes to your health insurance plan outside the standard Open Enrollment Period if you experience a qualifying life event. Typically, you have a 60-day window from the date of the event to make these adjustments.

For job-based insurance, employers must offer at least 30 days for enrollment during this period. Additionally, you can apply for Medicaid or the Children’s Health Insurance Program (CHIP) at any time if your income qualifies you for these programs.

4. What events qualify for a Special Enrollment Period?

Events that may qualify you for the SEP include:

  • Getting married
  • Having a baby, adopting, or fostering
  • Divorce or legal separation (Only if your marriage ended and you lost your health insurance as a result. Simply getting divorced without losing your coverage doesn’t qualify.)
  • Losing someone
  • Moving to a new home
  • Loss of health coverage (This does not apply to loss of coverage resulting from failure to pay premiums.)
  • Joining a federally recognized tribe or gaining status as a shareholder of an Alaska Native Claims Settlement Act (ANCSA) Corporation.
  • Gaining US citizenship
  • Being released from incarceration
  • Beginning or completing service as a member of AmeriCorps State and National, VISTA, or NCCC.

Other situations that may grant eligibility for the SEP are:

  • Unexpected Situations: If you were prevented from enrolling on time due to a medical condition, natural disaster, or state-level emergency. For natural disasters, you need to have lived in an area declared for FEMA assistance.
  • Errors During OEP: If errors or misinformation from someone assisting with your enrollment (such as an insurance company, navigator, or agent) prevented you from enrolling in a plan or receiving the correct premium tax credits.

This also applies if technical issues on HealthCare.gov, like error messages or incorrect plan details, stopped you from enrolling or if your insurance company didn’t receive your enrollment information correctly.

  • Eligibility Changes: If you recently gained eligibility for savings (such as after moving or an income increase), or if you were wrongly told you might qualify for Medicaid/CHIP and were later found ineligible after OEP.
  • Court Orders: If a court order, such as a child support order, changed your dependent status. Your coverage will begin on the effective date of the court order, even if you enroll in the plan up to 60 days afterward.
  • Domestic Abuse or Spousal Abandonment: If you've experienced domestic abuse or spousal abandonment, you can apply for your own health insurance plan separate from your abuser. Your dependents may also qualify for coverage.

If you're still legally married, you can state on your Marketplace application that you're unmarried. Based on your income, you might qualify for premium tax credits and other discounts.

5. What documents do I need to submit to prove my eligibility for a Special Enrollment Period?

To prove your eligibility, you may need to submit different documents depending on your qualifying event. Here are common examples:

A. Due to the Loss of Health Coverage

To confirm the loss of health coverage, you need to provide a document on official letterhead that includes your name and the date your coverage ended or will end. This can be:

  • A letter from your insurance company, employer, or COBRA administrator confirming the termination or upcoming end of your coverage.
  • If your coverage was through a government health program (like TRICARE, VA, or Medicare), submit a letter from the relevant program.
  • For Medicaid or CHIP, provide a letter from your state agency showing the denial or termination of your coverage.
  • A military discharge document (DD214) if your coverage ended when you left the military.
  • For student health coverage, submit a letter from your school or health plan provider showing the coverage end date.

In some cases, additional documentation is required to verify specific life events. For instance, if you lost employer-sponsored coverage, you may also need to provide:

  • Two pay stubs, one showing a deduction for health coverage from the last 1-3 months and another showing that the deduction occurred within the past 60 days.
  • If a reduction in work hours caused you to lose coverage, provide one previous pay stub showing that you worked 30 or more hours and a deduction for health coverage, along with a more recent pay stub showing you worked fewer than 30 hours with no health coverage deduction.

B. Due to a Move

To prove your move and confirm your eligibility, here's what you can submit:

  • Bills or Financial Statements:
    • Mail from a bank or financial institution.
    • Utility bills (internet, cable, phone, gas, water) showing the start date of services at the new address.
    • A US Postal Service change of address confirmation letter with the forwarding date.
  • Housing Documents:
    • A mortgage deed stating the property is your primary residence.
    • A rental or lease agreement with the start date at your new address.
    • A homeowner’s or renter’s insurance policy showing the start date at your new address.
  • Government Letters:
    • A letter from a government agency (e.g., Social Security, SNAP, TANF) on official letterhead showing the change of address.
    • Mail from the DMV, IRS, or LIHEAP
    • A voter registration card
  • If you’re homeless or in transitional housing, you need a reference letter from someone who can confirm you live permanently in the area (friend, family member, or caseworker), along with a document proving their residency.
  • If you moved from a US territory, you need proof of your previous residency in the territory, such as:
    • A government-issued ID, voter registration card, or other official identification showing your address in a US territory.
    • A document showing your previous address, dated within 12 months before your move, and a document showing your new address, dated within 60 days after your move.
  • If you moved from a foreign country, you need proof of your entry, such as:
    • An I-94 Arrival/Departure Record
    • A passport with an admission stamp showing your entry date into the US.
  • If you moved within the US, you must also show that you had qualifying health coverage for at least one day in the 60 days before your move. Acceptable documents include a letter (on official letterhead) from your provider confirming your health coverage.

C. Due to a Court Order

If you lost coverage due to a court order, such as a divorce or legal separation, submit documents showing when your coverage ended, including:

  • Divorce or annulment papers showing the date you stopped being responsible for providing health coverage or when you lost coverage due to your relationship with your former spouse.
  • Legal separation papers showing the date when responsibility for health coverage ended.

D. Due to the Death Of A Family Member

If you lost coverage due to the death of a family member, provide:

  • A death certificate or public notice of death, along with proof that you were covered under the deceased person’s plan (such as a letter from an insurance company or employer listing the names of those covered on the plan).
  • Other documents showing that you lost coverage because of the death of your spouse or family member.

E. Due to an Adoption, Foster Care, or Court Order

These documents must include the dependent's name and the date they became a dependent. Acceptable documents include:

  • Adoption records or foster care papers signed by a government or court official.
  • Court order (e.g., child support)
  • A government-issued document for legal guardianship.
  • Medical support order
  • If you adopted a child from a foreign country, provide an immigration document from the US Department of Homeland Security (DHS) that shows the adopted person’s name and the date of the adoption.

After submitting the necessary documentation, the marketplace or your insurance provider will review and confirm your eligibility for SEP.

6. What can I do if my request for a Special Enrollment Period is denied?

In the Marketplace, you typically have 90 days from the date listed on your Eligibility Notice to request an appeal. The process for filing your appeal, as well as the form you use, depends on where you live and whether you have a Marketplace account.

You can submit your appeal in two ways:

A. Filing SEP Appeal Online

Filing online is the quickest option. Here's what to do:

  • If you have a Marketplace account, Log in (or create an account if you don’t have one). Select your current application, then navigate to "Eligibility & appeals" and click on "File new appeal or check your appeal's status."
  • If you’re assisting someone or don’t have a Marketplace account, you can still file online by completing this form through DocuSign.

B. Filing SEP Appeal Through Mail or Fax

You can also submit your appeal by downloading the appeal form. Follow the instructions carefully to prevent delays in processing. Make copies of the form and send it to the following address:

  • Mailing address:

Health Insurance Marketplace

Attn: Appeals

465 Industrial Blvd.

London, KY 40750-0061

  • Secure fax line: 1-877-369-0130

Appeals are usually processed in the order they are received. The time it takes for a decision varies depending on the issue you're appealing, whether the appeal is expedited, and if additional documents are needed.

7. What types of health insurance plans are available during the OEP and SEP?

During both the OEP and SEP, you can choose from a variety of health insurance plans, including:

A. Health Maintenance Organization (HMO) Plans

HMOs require you to choose a primary care doctor and get referrals for specialists. They offer low premiums but only cover care from in-network providers, except in emergencies.

B. Preferred Provider Organization (PPO) Plans

PPOs provide more flexibility in choosing doctors and specialists, covering both in-network and out-of-network care. You don’t need a referral, but premiums are higher than HMOs.

C. Exclusive Provider Organization (EPO) Plans

EPOs only cover care from in-network providers, like HMOs, but don’t require referrals. They offer moderate premiums with fewer restrictions than HMOs but no out-of-network coverage.

D. Point of Service (POS) Plans

POS plans combine features of HMO and PPO plans. You need a primary care doctor and referrals, but can see out-of-network providers at a higher cost. In-network care is more affordable.

E. Catastrophic Health Plans

Catastrophic plans have low premiums and are available to people under 30 or with hardship exemptions. They cover major emergencies but come with high deductibles.

F. High-Deductible Health Plans (HDHP)

HDHPs have low premiums and high deductibles, ideal for healthy individuals. Often paired with a Health Savings Account (HSA) to save for medical expenses.

G. Medicare and Medicare Advantage Plans (OEP Only)

Medicare is for those 65+ or disabled. Medicare Advantage offers extra benefits, like dental and vision, with lower premiums but often limits you to a network of providers.

H. Medicaid and Children’s Health Insurance Program (CHIP)

Medicaid offers low or no-cost health coverage for low-income individuals. CHIP covers children from low-income families. Both programs have minimal out-of-pocket costs.

These plans address a range of needs and budgets with options suited to your healthcare preferences and financial situation.

Wrap-up

The open and special enrollment periods for health insurance are essential for securing the right health insurance coverage. The OEP gives you an annual opportunity to sign up or make changes to your health plan, ensuring you’re covered for the upcoming year.

If you experience a qualifying life event, the SEP allows you to adjust your coverage outside of the OEP, ensuring you maintain access to healthcare during key life transitions. By staying informed about these enrollment periods and meeting the necessary deadlines, you can make sure you have the right health insurance to meet your needs when it matters most.

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