I Missed Open Enrollment. What Should I Do?

It is a common concern to find oneself past the annual open enrollment period for health insurance, the designated time each year when individuals can sign up for, change, or re-enroll in a health plan. While this window is crucial for securing coverage, pathways to coverage often remain available even after this deadline.

Special Enrollment Periods: Eligibility and Qualifying Life Events

A Special Enrollment Period (SEP) allows individuals to enroll in health insurance coverage outside of the standard annual open enrollment period. These periods are triggered by specific life changes, known as Qualifying Life Events (QLEs), which are significant shifts in an individual’s personal circumstances that affect their household, living situation, or access to health coverage.

One common QLE is a change in household size, such as getting married or entering into a domestic partnership, which generally grants a special enrollment opportunity. The birth of a child, adoption, or placement of a child for foster care also qualifies an individual for an SEP, allowing them to add new family members to a health plan. Losing existing health coverage is another frequent trigger for an SEP, which can occur due to job loss, divorce, or aging off a parent’s plan, such as turning 26. Individuals who lose coverage through Medicaid, the Children’s Health Insurance Program (CHIP), or COBRA may also qualify for an SEP.

Moving to a new permanent residence in a different state or county where new health plan options become available constitutes a QLE. This also applies to individuals moving into the United States from a foreign country or a U.S. territory. Significant changes in income that affect eligibility for subsidies or financial assistance can also initiate an SEP, particularly if the change allows an individual to qualify for new financial aid categories. Generally, individuals have a 60-day window, either before or after the qualifying life event, to select a new health plan.

How to Apply for a Special Enrollment Period

Once a Qualifying Life Event (QLE) has been identified, the next step involves applying for a Special Enrollment Period (SEP). For those seeking coverage through the Health Insurance Marketplace, the official government website, Healthcare.gov, is the primary avenue for application.

The application process requires submitting documentation to verify the QLE. For instance, a marriage certificate is needed for a marriage-related SEP, while a birth certificate or adoption decree would be necessary for the addition of a child. If the QLE is due to the loss of prior coverage, a termination notice from the previous insurer or employer may be required.

After submitting the application and supporting documentation, the Marketplace will review the information to confirm eligibility for an SEP. This review may involve a waiting period, and in some cases, additional information may be requested to further substantiate the QLE. Upon approval, individuals can then select a health plan from the available options, with coverage typically beginning on the first day of the month following plan selection.

Alternative Coverage Options Outside of SEPs

If an individual does not qualify for a Special Enrollment Period or has missed the SEP window, other avenues for obtaining health coverage may still be available. One option is Medicaid, a joint federal and state program providing health coverage to low-income adults, children, pregnant women, elderly adults, and people with disabilities. Eligibility for Medicaid and the Children’s Health Insurance Program (CHIP) is determined by income and family size, and enrollment for these programs is open year-round.

Another alternative for those who recently lost employer-sponsored health coverage is the Consolidated Omnibus Budget Reconciliation Act (COBRA). COBRA allows eligible employees and their dependents to continue group health benefits provided by their previous employer for a limited period, typically 18 to 36 months, though often at a higher cost as the individual must pay the full premium plus an administrative fee. Some employers may also offer health benefits to new hires outside of the traditional open enrollment period, so individuals starting a new job should inquire about immediate coverage options.

Short-term health plans represent another option, though they differ significantly from comprehensive plans offered through the Marketplace or employer-sponsored plans. These plans are designed to provide temporary coverage for unexpected medical needs and are not subject to the same consumer protections as Affordable Care Act-compliant plans. Short-term plans often do not cover pre-existing conditions, essential health benefits, or prescription drugs, and they typically have lower annual limits on benefits.