[Infographic] 5 Questions to Ask About Special Enrollment Periods

Special Enrollment Summary Infographic

Updated January, 2020.

In general, people can only enroll in a health insurance plan during Open Enrollment. Medicare also has its own Annual Enrollment Period and its Initial Enrollment Period varies depending on your birth date.

However there are some exceptions, including Medicaid, CHIP, and qualifying for a Special Enrollment Period (SEP). If you qualify for a Special Enrollment Period, you have a certain amount of time to make changes to your health insurance plan or enroll in a new one to ensure that you maintain the health insurance coverage you need.

Here are some of the most common questions regarding Special Enrollment Periods (SEPs):

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What is a Special Enrollment Period?

Special Enrollment Periods (SEPs) let you make adjustments to your health insurance coverage or enroll in a new plan outside of Open Enrollment under certain circumstances. These circumstances are referred to as a Qualifying Life Event. Having missed Open Enrollment does not make you eligible to apply for a Special Enrollment Period.

Special Enrollment Periods typically last 30-60 days, which allows plenty of time for you to look at your health coverage options and make the necessary insurance coverage adjustments.

“Don't forget about deadlines, and keep in mind that they're different for employer-sponsored plans versus individual market plans. For employer-sponsored plans, you'll generally have 30 days, whereas in the individual market, you'll have 60 days (some qualifying events trigger a special enrollment period both before and after the event, whereas others are only after it),” says Louise Norris, licensed agent and author of Insider’s Guide to Obamacare’s Special Enrollment.

Whether you receive health insurance from your employer or purchase your own separately, you may qualify for a Special Enrollment Period as your life changes.

If you purchase health insurance independently, you can work with an insurance agent or use online tools that make it easy to explore all your options before you make a change.

“Never buy from an agent who only has one product. You need someone who can shop around effectively and give you options. Never call the health insurance marketplace on your own without guidance from an agent. The customer service reps are not agents, and you may not understand the rules and regulations they have,” Maria Townsend, Insurance Advisor, says.

HealthCare.gov shows all of the group health insurance plans created by the Affordable Care Act. After you complete a questionnaire, it will include any subsidies you qualify for in the listed premium quotes.

If you don’t want to buy a Marketplace plan, you can view covered benefits and costs (monthly premiums, deductibles, out-of-pocket expenses, etc.) offered by multiple companies by looking at a comparison website. A few health insurance comparison websites are HealthMarkets, HealthCare.com, and GoHealth.

It’s a good idea to be careful when shopping online. Some websites are designed to generate leads for health insurance providers and sell customer information to multiple insurance companies, instead of just connecting the customer to the company and plan they requested. If you can’t see price estimates and plan details before providing contact information, it may not be the best resource.

Townsend says, “I would stay away from the insurance sites that sell off your info for a price comparison, and later get 100 calls from different reps. Those sites never check your medications or doctor network to even know if it's a plan that meets your needs personally. I recommend sites like FreeInsuranceGuru.com, where you can chat, call, or even video chat with an agent licensed in your area and your information isn't sold.”

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What qualifies as a Special Enrollment Period?

A Special Enrollment Period occurs when you experience a Qualifying Life Event. These events are life changes like

  • Losing current health insurance
  • Moving
  • Getting married
  • Having a baby or adopting
  • Income changes
  • Gaining Tribe membership
  • Gaining U.S. citizenship
  • Release from prison
  • Starting or ending Americorps service

You can also qualify for a Special Enrollment Period if the company you enrolled with made an error in the information they provided or breached their Marketplace contract.

If you experience a qualifying event, you can make changes to your insurance coverage, like adding people to your current health plan.

Keep in mind that even if you have a Qualifying Life Event, other rules still govern Special Enrollment Periods.

Norris says, “In the individual market, keep in mind that most special enrollment periods now require that you had coverage prior to the qualifying event, so they serve as an option to change coverage rather than go from being uninsured to having coverage. So while getting married or moving to a new area used to allow a person to gain coverage after being uninsured, that's no longer the case (for marriage, at least one spouse must have had coverage prior to the marriage, although the other could have been uninsured).

Some individual market rules limit enrollees' ability to use special enrollment periods to upgrade their coverage during the year. All of this is opposed to open enrollment in the fall, when anyone can sign up or change their coverage, regardless of their prior insurance status.”

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What are my health insurance options?

For the most part, Special Enrollment Periods allow people to add a person to their current plan or enroll in a new plan.

If you’re enrolling in a new plan, you can enroll in

  • An employer-sponsored plan
  • A Marketplace plan
  • A private insurance plan

Research to learn the health insurance plans available to you and what they cost.

If you’re losing insurance coverage because you left a job and are starting a new one, it’s a good idea to enroll in some kind of health insurance plan. Most employers have a waiting period before new employees can enroll in health insurance. 

To ensure that you have coverage during the waiting period, you can buy temporary health insurance, enroll in a Marketplace plan, be added to your spouse’s employer plan, or extend your employer’s health insurance coverage using COBRA.

“Nobody needs a qualifying event to enroll in a short-term plan, as they're available year-round but with medical underwriting. However, it's also common to see short-term plans being marketed to people who are aging off their parents' health plan or losing access to an employer-sponsored plan when they quit their job. In both cases, the person is actually eligible for a SEP in the individual market (where there's no medical underwriting, pre-existing conditions are covered, and the plans include essential health benefits coverage), but people sometimes enroll in short-term plans because they aren't sure what other options they have,” Norris says.

Short-term health insurance plans are an option that’s always available. They can be a good choice, but don’t offer the complete coverage that standard health insurance plans offer.

If your spouse has insurance through their employer, you can also be added to their plan.

“The qualifying event that triggers COBRA eligibility (and the SEP in the individual market) will also trigger a SEP that would allow the person to join their spouse on the spouse's employer-sponsored health plan (assuming the spouse has such coverage and the plan offers spousal coverage). But as noted above, that SEP only has to last 30 days, whereas it's 60 days in the individual market and there's a 60-day window for COBRA,” Norris says.

What is COBRA Insurance?

COBRA stands for the Consolidated Omnibus Budget Reconciliation Act. It is the legislation that allows former employees to continue health insurance coverage from their former employer for a certain amount of time until they find new coverage up to 18 months. 

Individuals who use COBRA coverage must pay the employer’s contribution and an administrative fee in addition to the monthly premiums.

Norris says, “If you're being offered COBRA, take your time to compare individual market plans and COBRA — you don't want to jump into either option without understanding all the details, but you've got 60 days to make your decision.”

When choosing between enrolling in a new plan or COBRA, research your options.

Townsend suggests, “Reach out to an experienced insurance agent, who can provide you many options and speak to you intelligently about what options they have for you verses the COBRA route. Go online and shop if you enjoy shopping online!”

Evaluating the costs and benefits of using COBRA versus another health insurance plan will help you make the best decision for your circumstances. The nice thing about using COBRA is that the coverage can be retroactive if you enroll later during your Special Enrollment Period.

Norris offers a few scenarios in which COBRA may be ideal:

  • “You're in the middle of a complicated course of treatment and don't want to have to worry about switching providers, dealing with a new drug formulary, etc. So a person going through cancer treatment, for example, might be better off with COBRA than with switching to the individual market.
  • You've already met or nearly met your out-of-pocket maximum for the year. If you switch to a new plan in the individual market — even if it's from the same insurer that offers your group benefits — you'll have to start over with your out-of-pocket expenses.
  • Your income is too high for premium subsidies and you're fairly certain you're going to have access to a new employer-sponsored plan soon. In that case, keeping COBRA will be less complicated than having to enroll in a new plan only to switch away from it again in the near future when you switch to the new employer-sponsored plan.”

However, there are a few reasons why enrolling in a new plan might be better.

“An individual market plan might be much less expensive, especially if you qualify for premium subsidies and/or pick a plan with higher out-of-pocket exposure than the one you had through your employer. Premium subsidies are available this year to a family of four with MAGI as high as $100,400, whereas there's no financial assistance available to offset the cost of COBRA.

Depending on the specifics of the plan you had through your employer and the options that are available in the individual market in your area, you might find that you can pick an individual market plan that has a provider network and/or drug formulary that work better for you,” says Norris.

If you’re eligible for COBRA and Medicare, you might want to enroll in both or opt for Medicare.

“One serious mistake I see people make with COBRA is when they are also eligible for Medicare. They elect COBRA, but do not enroll in Medicare Part B. Medicare says you need to enroll in Part B even when electing COBRA and over age 65. Failing to do so can cause a lifetime Part B premium penalty because of a late enrollment fee,” advises Adam Hyers, owner of Hyers & Associates Insurance Agency.

How do I sign up for COBRA?

Employers are required to offer information on COBRA and enrolling in COBRA to their employees. Your employer’s human resources department can answer your questions and help you access coverage through COBRA.

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How do I apply for a Special Enrollment Period?

For the most part, it’s not a matter of applying for a Special Enrollment Period, it’s a matter of enrolling in a health insurance plan or making adjustments to your coverage.

If you have a qualifying life event, talk to your employer’s human resources department. The human resources team will help you through the process--whether you are enrolling in a different plan, making adjustments to add coverage, or using COBRA.

If you don’t have insurance through your employer, contact your health insurance company. They will tell you what documentation they need and help you with the changes you need to make.

If you’re choosing a new health insurance plan, research your options online. You can view your options by looking directly at company websites, looking at comparison websites, or looking at Marketplace plans on HealthCare.gov. Representatives from these websites can also help with the enrollment process.

Getting advice from a licensed independent agent is always a good idea, especially if you’re working directly with a company.

“I always stress the importance of sitting down with a licensed, non-biased insurance agent who can provide information on coverage and price on various policies from an array of carriers so you can find the policy that best meets your needs and budget. Whether you are enrolling in ACA or COBRA, understanding what is and is not covered and what the cost will be to you (and your family, if applicable) is very important,” says Chris Mason, Senior Vice President of Sales Distribution for HealthMarkets.

If you are required to give documentation to show that you qualify for a Special Enrollment Period, do not send the originals. Make copies to send in and keep the originals for you records.

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What is a Special Enrollment Period for Medicare?

Medicare Special Enrollment Periods are slightly different from regular Special Enrollment Periods, although the concept is the same. There are a few more situations that allow for a Special Enrollment Period. The length of the Special Enrollment Period also varied based on the circumstance that triggers it. Start dates also vary.

Many of the Qualifying Life Events that trigger a Special Enrollment Period also trigger a Medicare Special Enrollment Period. However, some circumstances are distinct to Medicare.

For example, you qualify for a Medicare Special Enrollment Period if you have an opportunity to purchase other non-Medicare coverage or if your current Medicare plan changes its Medicare contract.

More information regarding Qualifying Life Events and corresponding Special Enrollment Period details, can be viewed on Medicare.gov.

Understanding how Special Enrollment Periods work will help you be prepared, use the time offered to understand your options, and make sure that you have the coverage you need.

For more information on Special Enrollment Periods, check out Health Insurance Marketplace’s Guide.

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