Special Enrollment Periods and Triggering Events

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Individual Health Insurance Exchange

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Individual & Family Plans – Ages 19 – 64
Child Only Plans – Ages 0-18
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Special enrollment periods will last for 60 days from the date of the triggering event unless the regulation specifically provides otherwise.

All requests for special enrollment periods must be evaluated by the Exchange as part of the eligibility determination process.

For purposes of special enrollment periods, a dependent is any individual who is or may become eligible for coverage under the terms of a QHP because of a relationship to an enrollee.

Triggering Events:

  • Loss of other minimum essential coverage, defined as any event that triggers a loss of eligibility for other minimum essential coverage.
  • Examples would include:
    • o Decertification of a QHP outside of the annual open enrollment period;
    • o Legal separation or divorce ending eligibility of a spouse or step-child as a dependent;
    • o End of dependent status;
    • o Death of an individual enrolled in minimum essential coverage ending eligibility for covered dependents;
    • o Termination of employment or reduction in the number of hours required to maintain coverage;
    • o Relocation outside the service area of the QHP.
    • o Termination of employer contributions for a qualified individual or dependent who has coverage that is not COBRA continuation coverage;
    • o Exhaustion of COBRA continuation coverage;
    • o Reaching a lifetime limit on all benefits in a grandfathered plan;
    • o Termination of Medicaid or CHIP.

HHS is seeking comment on its limitation of the special enrollment period to only those who lose minimum essential coverage, as opposed to any coverage. This was done to avoid adverse selection.

 

  • Addition of a dependent through marriage, birth, adoption, or placement for adoption;

HHS seeks comments as to whether States might consider expanding the special enrollment period to include gaining dependents through other life events.

  • Error in enrollment where the Exchange finds that enrollment or non-enrollment in a QHP is unintentional, inadvertent or erroneous and is the result of the error, misrepresentation, or inaction of an officer, employee, or agent of the Exchange or HHS, or its instrumentalities as evaluated and determined by the Exchange.
  • QHP in which an individual was enrolled substantially violated a material provision of its contract in relation to such individual and their dependents. One example would be misrepresentation of the plan while marketing.
  • Becoming newly eligible or newly ineligible for premium tax credits or a change in eligibility for cost-sharing reductions.