What to Do If You Miss Open Enrollment for Health Insurance?

Missing the annual open enrollment period for health insurance does not mean being without coverage. Specific pathways and options are available to secure health insurance outside the standard enrollment period. This article explains how to obtain health insurance when regular enrollment has closed.

Qualifying for a Special Enrollment Period

A primary method for securing health insurance outside the standard open enrollment period is through a Special Enrollment Period (SEP). An SEP is a designated time outside the yearly Open Enrollment Period when individuals can sign up for health insurance due to specific life events that impact their health coverage needs.

Qualifying life events that trigger an SEP generally fall into categories such as loss of health coverage, changes in household, and changes in residence. Losing existing health coverage often qualifies individuals for an SEP, including events like job loss, losing eligibility for Medicare or Medicaid, or turning 26 and no longer being covered under a parent’s plan. Household changes like getting married, getting divorced or legally separated and losing health insurance, having a baby, or adopting a child can also trigger an SEP.

Moving to a new area that offers new health plans, or moving to the U.S. from a foreign country or U.S. territory, typically qualifies an individual for an SEP. Other qualifying situations might include changes in citizenship status, leaving incarceration, or gaining membership in a federally recognized tribe. Certain changes in household income may also make an individual eligible for an SEP.

Following a qualifying event, individuals generally have a limited timeframe to act, typically 60 days before or 60 days after the event date, to enroll in a new plan. For some events, like the birth of a child, coverage can begin on the day of the event, even if enrollment occurs up to 60 days afterward. Job-based plans are required to provide an SEP of at least 30 days.

To prove eligibility for an SEP, documentation is typically required to verify the qualifying life event. The specific documents needed will vary based on the type of event.

For instance, a marriage certificate or divorce paperwork may be needed for household changes. Birth certificates or adoption records are generally required for new family members. Proof of address change, such as new rental agreements or utility bills, can verify a move. Documentation showing loss of prior coverage, such as a letter from a former employer or insurance provider, is also commonly required.

Plans accessed through an SEP are available on the Health Insurance Marketplace (HealthCare.gov) or state-run marketplaces. These plans offer the same consumer protections as those available during the annual open enrollment period.

Considering Other Health Coverage Options

Individuals who do not qualify for an SEP or need different coverage have several alternative health options. These cater to various circumstances, including income, age, and temporary needs, each with distinct characteristics and eligibility requirements.

Medicaid and the Children’s Health Insurance Program (CHIP) provide year-round health coverage for low-income individuals and families. Eligibility is primarily based on household income and size, though factors like pregnancy or disability can also apply. Income limits vary by state, and some states have expanded Medicaid to cover more people.

Short-term health insurance plans offer temporary coverage to bridge gaps between more comprehensive plans. These plans are not subject to all Affordable Care Act (ACA) requirements, meaning they may not cover pre-existing conditions or have limits on benefits. They typically last for a limited duration and are purchased directly from private insurance companies, not the Health Insurance Marketplace. They can be a suitable temporary solution while awaiting other coverage or during transitional periods.

Employer-sponsored health plans offer another pathway. New employees often have an enrollment period to select coverage through their employer. For those who recently left a job, the Consolidated Omnibus Budget Reconciliation Act (COBRA) may allow continuation of previous employer coverage for a limited time, typically up to 18 months, by paying the full premium plus an administrative fee. COBRA generally applies to employers with 20 or more employees. State continuation laws may offer similar options for smaller employers.

Medicare is a federal health insurance program primarily for individuals aged 65 or older, or those with certain disabilities. Medicare has specific enrollment periods. The Initial Enrollment Period (IEP) is a seven-month window around an individual’s 65th birthday. There is also a General Enrollment Period (GEP) from January 1 to March 31 each year for those who missed their IEP, though late enrollment penalties may apply.

Applying for Coverage Outside Open Enrollment

Once a suitable health coverage option is identified, the next step involves navigating the application process. The specific procedures for applying vary significantly depending on the type of plan. It is important to have all necessary documentation prepared.

For Marketplace plans accessed through an SEP, the application typically begins on HealthCare.gov or a state-run marketplace website. Create an account and select the option to apply due to a qualifying life event. Input personal and household information, including details about the qualifying event and income. After selecting a plan, submit supporting documents, such as marriage certificates or proof of job loss, digitally or by mail to verify eligibility for the SEP and any financial assistance. Coverage generally begins after the first premium payment and qualifying event confirmation.

To apply for Medicaid or CHIP, individuals can do so through their state Medicaid agency or by completing an application on the Health Insurance Marketplace. If applying through the Marketplace, information is securely forwarded to the relevant state agency if anyone in the household qualifies. The state agency will then contact the applicant regarding enrollment. Required documentation for Medicaid applications can include proof of income, citizenship or immigration status, and household size, though specific requirements vary by state.

Short-term health insurance plans are typically purchased directly from private insurance companies or through licensed insurance brokers. The process usually involves obtaining quotes and completing an application online or over the phone. These applications often include health questions, as short-term plans are medically underwritten and may deny coverage based on pre-existing conditions. Coverage can sometimes begin as quickly as the next day after approval and payment.

Enrolling in an employer-sponsored health plan generally involves coordinating with the employer’s Human Resources (HR) department. For new employees, enrollment usually occurs during a specific new hire enrollment period. If enrolling due to a qualifying life event, the HR department will provide the necessary forms and guidance. For COBRA continuation coverage, the former employer or plan administrator will provide an election notice, and individuals typically have at least 60 days to decide whether to elect coverage. Payment of the full premium, plus an administrative fee, is required to maintain COBRA coverage.