- Exceptional circumstances — personal or widespread — can trigger an SEP
- Domestic violence or spousal abandoment
- Enrollment errors or delays
- Contract violations (changes to the provider network or drug formulary are NOT considered contract violations)
In addition to the qualifying events already discussed in the previous sections, there are a range of other circumstances that will allow you to enroll in a plan through the exchange after open enrollment has ended for the year. These are all case-by-case situations, and they all apply on-exchange, although off-exchange carriers can allow for enrollment flexibility for these situations too.
If “exceptional circumstances” occur during open enrollment (or in some cases, prior to open enrollment), and you can demonstrate to the exchange that the circumstances prevented you from enrolling by the end of open enrollment, the exchange can grant you a special enrollment period.
Exceptional circumstances can be personal – for example, a house fire or a serious medical condition that made it impossible for you to enroll – but they also include natural disasters that impact a large number of people. They can also be triggered by political or regulatory changes.
For example, Minnesota’s exchange used the exceptional circumstances provision to issue a week-long special enrollment period at the end of the open enrollment period for 2017 coverage, in order to allow Minnesota residents to take advantage of a newly-enacted state premium rebate (the legislation for the rebate was signed just a few days before the end of open enrollment).
In cases of serious natural disasters, the exchanges are likely to issue blanket extensions. This was the case in several states for 2018 coverage following the 2017 hurricane season that caused significant damage along the Gulf coast. HHS announced that there would be a special enrollment period through December 31, 2017 (and later extended through March 31, 2018) for anyone living in areas that FEMA deemed eligible for public assistance or individual assistance following Hurricanes Irma, Maria, Nate, and Harvey)
Regardless of where you live, if you believe that you experienced an exceptional circumstance that prevented you from enrolling during open enrollment, reach out to the exchange as soon as possible to make your case and request a special enrollment period. The exchange will consider the circumstances and make a decision about your eligibility for a special enrollment period on a case-by-case basis.
Domestic violence or spousal abandonment
Victims of domestic violence or spousal abandonment are eligible to enroll in a plan on their own (or with their children), separate from the partner who abused and/or abandoned them. This is true regardless of whether the abuse or abandonment happens outside of open enrollment
Under normal circumstances, married enrollees are only eligible for subsidies in the exchange if they file a joint tax return, and their exchange enrollment must include total household income. But there’s an exception for victims of domestic violence or spousal abandonment. In those circumstances, the victim can state that he or she is unmarried on the exchange application, and eligibility for premium subsidies and cost-sharing subsidies will be calculated based on the enrollee’s income alone.
Enrollment errors and delays
There are a variety of errors and delays that could occur during the regular open enrollment period. To provide flexibility for the exchanges to deal with these issues, HHS included them in the category of qualifying events:
- Your enrollment – or lack thereof – was the result of an error, misrepresentation, misconduct, or inaction on the part of the exchange, one of its representatives, or an enrollment assister. It’s a good idea to keep notes with details about the steps you take to enroll during open enrollment, so that you have documentation in the event that you need to show that errors occurred. This sort of scenario doesn’t happen too often now that the exchanges have had a few years to work out most of their bugs, but mistakes can still happen, and a special enrollment period to sort out the problems is an important safeguard.
- Your eligibility determination (for Medicaid/CHIP, premium subsidies, and/or cost-sharing subsidies) or coverage effective date was incorrect, and you filed a successful appeal with the exchange. If the appeal process finds that the initial eligibility determination and/or effective date were incorrect, you’ll have an opportunity to enroll again with the correct information, even if open enrollment has ended by that point.
- A technical error occurred during your enrollment, or the plan information was incorrectly displayed on the exchange website.
- You’re a recent immigrant (not eligible for Medicaid) with a household income under 100 percent of the poverty level, and you didn’t enroll in coverage while waiting for the exchange to determine your eligibility for subsidies in the exchange. Once the determination is made, you have access to a special enrollment period (this was clarified in the 2018 Benefit and Payment Parameters, page 247)
- You applied for Medicaid or CHIP during open enrollment, and although you were deemed ineligible, the determination wasn’t made until after open enrollment ended. Medicaid and CHIP enrollment continue year-round, but exchange enrollees who are applying for subsidized qualified health plans (QHPs) must first be screened to ensure that they aren’t eligible for Medicaid or CHIP.
Once the state Medicaid/CHIP agency has determined that an applicant is ineligible, the exchange can enroll the applicant in a subsidized QHP. But if the ineligibility determination for Medicaid/CHIP isn’t made until after open enrollment ends (despite the fact that the applicant initiated the process during open enrollment), the exchange can grant a special enrollment period during which the applicant can select a QHP and finish the enrollment process.
The QHP in which you’re enrolled “substantially violated a material provision of its contract” with you. “Substantial violations” have to be investigated, and there’s an official process for this.
It’s important to note that things like formulary changes and network changes can happen mid-year and do not constitute substantial violations. But if you think that your health plan has substantially violated its contract, you can contact the exchange and/or the state department of insurance for instructions on how to proceed.
Louise Norris is an individual health insurance broker who has been writing about health insurance and health reform since 2006. She has written dozens of opinions and educational pieces about the Affordable Care Act for healthinsurance.org. Her state health exchange updates are regularly cited by media who cover health reform and by other health insurance experts.
Source: health insurance