Can You Buy Health Insurance Outside of Open Enrollment?

It is widely known that health insurance enrollment typically occurs during a specific annual Open Enrollment Period. This designated timeframe allows individuals to select or change their health plans for the upcoming year. However, life circumstances often necessitate obtaining coverage outside this standard window. Various situations, such as a change in family status or a loss of existing coverage, may make individuals eligible to enroll in a health plan at other times.

Qualifying for a Special Enrollment Period

A Special Enrollment Period (SEP) allows enrollment in a Health Insurance Marketplace plan outside the regular Open Enrollment Period. These periods are generally triggered by specific qualifying life events (QLEs) that involve changes in one’s life situation. Individuals typically have a 60-day window following a QLE to select a new health plan.

Many common situations can qualify an individual for an SEP. These include losing existing health coverage, such as job-based insurance, COBRA coverage ending, or losing eligibility for Medicaid or the Children’s Health Insurance Program (CHIP). Changes in household size, like getting married, having a baby, adopting a child, or experiencing a divorce or death in the family, also qualify. Moving to a new residential area, becoming a U.S. citizen, or leaving incarceration are other examples. Income changes affecting subsidy eligibility can also trigger an SEP, particularly if an individual becomes newly eligible for help paying for Marketplace coverage.

To confirm eligibility for an SEP, the Health Insurance Marketplace requires specific documentation. For instance, a marriage certificate might be needed for a marriage QLE, while a birth certificate or adoption record would be required for adding a child. Proof of previous coverage loss, such as a letter from an insurance company or employer, is necessary when losing prior health benefits. For a change in residence, documents like rental leases or utility bills showing the new address are typically requested.

The application process for an SEP through the Health Insurance Marketplace, or a state-based exchange, begins by creating an account and reporting the qualifying life event. After submitting the application, individuals must provide supporting documents to verify eligibility. It is best to select a plan first, then submit documents within a specified timeframe, often 30 days after choosing a plan. Coverage typically starts on the first day of the month after a plan is selected and the first premium payment is made.

Medicaid and Children’s Health Insurance Program (CHIP)

Medicaid and the Children’s Health Insurance Program (CHIP) offer year-round enrollment opportunities for eligible individuals and families, making them distinct from the time-limited Special Enrollment Periods. These government programs provide health coverage based on income and household size relative to the Federal Poverty Level (FPL). Eligibility thresholds vary by state, particularly for adults, depending on whether the state has expanded its Medicaid program. In states that expanded Medicaid, adults under age 65 may qualify with income up to 138% of the FPL.

Medicaid offers comprehensive health coverage, including doctor visits, hospital care, prescription drugs, and preventive services. CHIP provides low-cost health coverage for children in families who earn too much for Medicaid but cannot afford private insurance. Both programs also cover pregnant individuals and people with disabilities, often at higher income levels.

Applications for Medicaid and CHIP are accepted at any time during the year. Individuals can apply directly through their state’s Medicaid agency or by submitting an application through the Health Insurance Marketplace. If applying through the Marketplace, information for eligible household members is forwarded to the state agency. Required documentation may include proof of income, Social Security numbers, and verification of citizenship or immigration status, though specific requirements can vary by state.

Employer-Sponsored Health Plans

Many individuals obtain health insurance through their employer, and there are specific windows for enrollment outside of the annual open enrollment period for these plans. When starting a new job, new employees generally have a limited timeframe to enroll in their employer’s health plan. This initial enrollment window is often around 30 days from their date of hire. Some employers may offer a slightly longer period, such as 60 days.

Similar to the Health Insurance Marketplace, certain qualifying life events also trigger special enrollment opportunities for employer-sponsored plans. If an employee experiences a QLE, such as getting married, having a baby, or losing other health coverage, they can typically add themselves or dependents to their employer’s plan outside of the regular open enrollment. This allows for adjustments to coverage as life circumstances change throughout the year.

Enrollment in an employer-sponsored plan usually occurs through the company’s Human Resources department or an online benefits portal. Employers generally communicate the specific deadlines and processes during the onboarding period. The Affordable Care Act (ACA) prohibits employer-sponsored plans from imposing waiting periods that exceed 90 days before coverage can begin. This regulation helps ensure new employees can access health benefits promptly after starting a new position.

Short-Term Health Insurance and Medicare

For those seeking immediate but temporary coverage, short-term health insurance plans are an option, though they differ significantly from comprehensive ACA-compliant plans. These plans are primarily designed to bridge gaps in coverage, such as during a transition between jobs or while waiting for other insurance to begin. Short-term plans can typically be purchased at any time of year, offering flexibility for urgent needs.

A key distinction is that short-term health insurance plans are not required to comply with the Affordable Care Act’s standards. They generally do not cover pre-existing conditions, may not include all essential health benefits, and can have annual or lifetime dollar limits on benefits. They are not considered minimum essential coverage, so losing a short-term plan does not qualify an individual for a Special Enrollment Period on the Marketplace.

Medicare provides health insurance primarily for individuals aged 65 or older, certain younger people with disabilities, and those with End-Stage Renal Disease. Enrollment in Medicare involves specific periods that are distinct from those for private health insurance. The Initial Enrollment Period (IEP) for most individuals is a seven-month window centered around their 65th birthday, beginning three months before, including the birth month, and extending three months after. During this time, individuals can enroll in Medicare Parts A and B.

If the IEP is missed, individuals may have another opportunity to enroll during the General Enrollment Period (GEP), which runs from January 1 to March 31 each year, with coverage starting the month after enrollment. However, late enrollment penalties may apply to Part B premiums if enrollment is delayed without qualifying circumstances. Medicare also has its own Special Enrollment Periods for specific situations, such as when an individual is still working past age 65 and has employer-sponsored coverage, allowing them to delay Part B enrollment without penalty. These specific enrollment windows help ensure access to Medicare benefits at appropriate times based on individual circumstances.