Can You Get Health Insurance Outside of Open Enrollment?

The annual Open Enrollment Period, typically from November 1st to January 15th, is the primary time to select or modify health insurance through the Health Insurance Marketplace. However, specific life changes can trigger exceptions, allowing enrollment outside this standard period.

Qualifying for a Special Enrollment Period

A Special Enrollment Period (SEP) allows individuals to enroll in a Qualified Health Plan outside of the annual Open Enrollment Period due to specific life events. These “Qualifying Life Events” (QLEs) involve changes in an individual’s household, residence, or current health coverage status. Individuals generally have a 60-day window, either before or after the QLE occurs, to apply for new coverage through an SEP. Missing this timeframe may result in having to wait until the next Open Enrollment Period to secure a health plan.

Changes in household composition frequently qualify for an SEP. This includes getting married, the birth of a child, adoption, or taking a child into foster care. A divorce or legal separation can also trigger an SEP. The death of a policyholder may also create an SEP for remaining family members.

Loss of other health coverage is another common QLE. This includes job loss, the end of COBRA coverage, or young adults aging off a parent’s health plan at age 26. Losing eligibility for programs like Medicaid or the Children’s Health Insurance Program (CHIP) can also open an SEP.

A permanent change in residence can also trigger an SEP. Changes in income that affect eligibility for financial assistance or government programs like Medicaid can also qualify an individual for an SEP.

Other QLEs include gaining U.S. citizenship, national status, or becoming a lawfully present individual. Leaving incarceration is also recognized as a qualifying event. For all QLEs, documentation must be from a legitimate source and dated within 90 days of the event to confirm eligibility.

Applying for Coverage During a Special Enrollment Period

After determining eligibility for a Special Enrollment Period, individuals can apply for health coverage. The primary platforms are HealthCare.gov, which serves most states, or state-specific marketplaces.

The application process begins by visiting the relevant online portal. Assistance is also available via phone or with in-person navigators. Applicants will need to provide personal information, details about their household, and income data. They must attest to the qualifying life event that makes them eligible for the SEP. After submitting the initial application, the marketplace will often request supporting documentation to verify the QLE.

Required documents correspond to the specific qualifying event. For example, a marriage certificate is needed for marriage, or a termination letter for job-based coverage loss. Proof of income, such as pay stubs or tax forms, may also be required for financial assistance eligibility. Documents are typically uploaded to the online portal.

After submission, the marketplace reviews documents to confirm SEP eligibility. It is advisable to submit all required documentation promptly, ideally within 30 days of selecting a plan, to avoid coverage delays.

Upon successful verification and plan selection, the effective date of coverage is determined. For many QLEs, coverage can begin on the first day of the month following plan selection. For certain events like the birth of a child, coverage can sometimes be retroactive to the date of the event, provided the application is made within the specified timeframe. Coverage generally commences once the first premium payment has been made directly to the insurance company.

Other Avenues for Health Coverage

Beyond Special Enrollment Periods through the Health Insurance Marketplace, other avenues exist for obtaining health coverage. Each has its own enrollment rules and eligibility criteria.

Medicaid and the Children’s Health Insurance Program (CHIP) offer health coverage to individuals and families with lower incomes. Unlike Marketplace plans, these programs do not have a limited open enrollment period; eligible individuals can apply and enroll at any time. Eligibility for Medicaid and CHIP is primarily based on Modified Adjusted Gross Income (MAGI) and family size, with specific income thresholds varying by state. Applications can be submitted directly through state Medicaid agencies or through the Health Insurance Marketplace.

Employer-sponsored health plans represent a significant source of coverage for many individuals. When starting a new job, employees are given an initial enrollment period to sign up for their employer’s health plan. The Affordable Care Act (ACA) limits waiting periods for new employees to no more than 90 days before coverage can begin. Employers also conduct an annual open enrollment period, allowing employees to make changes to their coverage or add dependents.

For those who lose job-based health coverage, COBRA (Consolidated Omnibus Budget Reconciliation Act) or state continuation coverage laws may offer a temporary extension of their previous employer’s health plan. COBRA applies to employers with 20 or more employees and allows individuals to continue coverage for a limited period, typically 18 to 36 months, after certain qualifying events like job loss or reduction in hours. While COBRA maintains the same benefits as the former employer plan, it often requires individuals to pay the full premium, plus a small administrative fee, which can be expensive.

Short-Term, Limited-Duration Insurance (STLDI) plans are another option, designed to provide temporary coverage for short gaps, such as between jobs. These plans are not subject to the same regulations as ACA-compliant plans and do not cover essential health benefits, pre-existing conditions, or offer the same consumer protections. They are less comprehensive and may have lower premiums but higher out-of-pocket costs and limitations on benefits.

Individuals may also explore direct enrollment with health insurance companies outside of the Marketplace. While some plans can be purchased this way, ACA-compliant plans still require a qualifying life event to enroll outside of the Open Enrollment Period. These direct purchase options may be suitable for those who do not qualify for Marketplace subsidies or prefer to work directly with an insurer.