What do I do if my situation changes during the year?

There are special enrollment periods for people who have life changes or other situations.  These include losing minimum essential coverage; gaining a dependent or becoming a dependent through marriage, birth, adoption or placement for adoption; becoming a citizen, national or lawfully present individual; or becoming newly eligible for a premium tax credit or cost-sharing assistance.

If one of these life changes happens to you, you’ll have 60 days to go back to the Insurance Marketplace to enroll in a Qualified Health Plan (QHP).

If you missed your 60 days; there are still other insurance plans you can enroll into such as Temporary Health Insurance or REALTORS® Core Health Insurance.  Understand, though, that these plans do not meet the standards of a QHP and a penalty may still apply.

Members should contact SASid’s professionally licensed staff at 877-267-3752 for advice and/or direction navigating their options.  Products and insurance companies may be different per exchange.

What and when is Open Enrollment for the Affordable Care Act?

Individuals may enroll in a Qualified Health Plan during various timeframes throughout the year. The timeframes are the open enrollment period, and special enrollment periods (SEP).

  • The Open Enrollment period for 2017 coverage started on November 1, 2016 and runs through January 31st, 2017. During this timeframe you will be able to change your coverage at will, for any reason.
  • SEPs occur throughout the year, based on individuals’ special circumstances.

Special Enrollment Periods

Under certain circumstances, individuals may change QHPs outside of the annual open enrollment period. These SEPs are based on certain triggering events or exceptional circumstances. Events that permit a SEP include, but are not limited to:

  • Gaining or becoming a dependent;
  • Gaining status as a citizen, national, or lawfully present individual;
  • Loss of minimum essential coverage (e.g., loss of Medicaid eligibility, termination of a QHP), except if enrollment is terminated based on failure to pay premiums;
  • Loss of affordable employer-sponsored coverage;
  • Determination that an individual is newly eligible or ineligible for premium tax credits or a change in eligibility for cost-sharing reductions;
  • Permanent move to an area where different QHPs are available;
  • Other exceptional circumstances identified by the Marketplace.

In most cases, SEPs will extend for 60 days from the date of the triggering event. Under certain circumstances, such as the pending loss of minimum essential coverage due to the termination of a QHP, a SEP may begin before the triggering event takes place.

Special Enrollment Period for Marriage

As mentioned in triggering events, a 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.

Special Enrollment Period for Birth or Adoption

Another important SEP exists for the birth or adoption of a child.

The effective date of coverage can be the date of the birth or the official date of adoption as long as the Individual Marketplace is notified in a timely manner.

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

Premiums would be pro-rated for the month, based on when the child was added to the policy.

NAR members should contact SASid’s professionally licensed staff at 877-267-3752 for advice and/or direction navigating their options.  Products and insurance companies may be different per exchange.