Affordable Care Act Open Enrollment FAQ for the Individual Market

Good stuff from BCBS of IL on when an individual can enroll in a health insurance plan.


May 29, 2013

Legislative Update
Affordable Care Act Question of the Week: Exchange Open Enrollment [All Markets]

We have received a number of questions about the initial open enrollment period for the Affordable Care Act (ACA). Beginning Jan. 1, 2014, most U.S. citizens and legal residents will be required to have a minimum level of health care coverage. If you have a general question about an ACA provision, contact your account representative.

Q: If an uninsured does not enroll through a health insurance exchange (also known as a health insurance marketplace) during the open enrollment period for coverage effective Jan. 1, 2014, under what circumstances may an individual enroll and receive coverage during 2014?

A: The initial open enrollment period for the exchange begins Oct. 1, 2013, and extends through March 31, 2014.

If an individual does not enroll during the initial open enrollment period or future enrollment periods (for plan years beginning on or after Jan. 1, 2015, the annual open enrollment period begins Oct. 15 and extends through Dec. 7 of the preceding calendar year), they can enroll if circumstances triggered one of the following events:

A qualified individual and any dependents losing other minimum essential coverage.
A qualified individual gaining or becoming a dependent through marriage, birth, adoption or placement for adoption.
An individual, not previously lawfully present, gaining status as a citizen, national or lawfully present individual in the United States.
A qualified individual experiencing an error in enrollment.
An individual enrolled in a Qualified Health Plan (QHP) adequately demonstrating to the exchange that the QHP in which he or she is enrolled substantially violated a material provision of its contract.
An individual becoming newly eligible or newly ineligible for advance payments of the premium tax credit or experiencing a change in eligibility for cost-sharing reductions.
New QHPs offered through the exchange becoming available to a qualified individual or enrollee as a result of a permanent move.
The individual is an Indian, as defined by the Indian Health Care Improvement Act. (We solicited comment on the potential implications on the process for verifying Indian status for purposes of this special enrollment period.)
A qualified individual or enrollee meeting other exceptional circumstances, as determined by the Exchange or Health & Human Services (HHS). Loss of coverage does not include failure to pay premiums on a timely basis, including COBRA premiums prior to expiration of COBRA coverage.
Unless specifically stated otherwise, an individual or enrollee has 60 days from the date of a triggering event to select a plan. Note: This 60-day Special Enrollment Period (SEP) window applies to the individual market. Group market is 30 days for the SEP window.