in English: Understanding special enrollment periods for health insurance

Even a minor illness or injury can cause considerable costs. The best way to reduce this risk is through health insurance. In general, you can only sign up for health coverage in two ways: during an open enrollment period or during a special enrollment period following a qualifying event.

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KEY TAKEAWAYS

  • Enrollment in Medicare has its own rules.
  • If you have a qualifying event, then you can buy or change your health insurance without waiting.
  • Some health insurance companies offer insurance coverage that can provide protection until the next opportunity arises.

What is open enrollment?

During a few months of the year, you can enroll in a health insurance plan through your employer, through your state's government-run Health Insurance Marketplace, or directly through an insurance company.

To receive a health insurance plan through work, your employer creates its own enrollment period, usually once or twice a year, and it's up to you to make any necessary changes within that period.

Individual health insurance purchased through the state insurance marketplace or directly from an insurance company has an annual open enrollment period from late fall through early next year. The next enrollment period is currently scheduled for November 1, 2016 through January 31, 2017. During this period, you can change your current plan or get new coverage.

 

What do I do if I missed the open enrollment period?

If you do not sign up for health insurance during the allotted period, you must wait until the next open enrollment period unless you have a qualifying event for a Special Enrollment Period or SEP.

If you have a qualifying event, you will be able to buy health insurance or change your existing coverage without having to wait until the next open enrollment period. If you do not have a qualifying event, you will be required to maintain your current insurance until the next enrollment period. As mandated by the Affordable Care Act, if you don't get health insurance or lose your health insurance and don't get replacement coverage, you will incur a monthly penalty (see penalty description below).

 

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Can I make changes to my health insurance policy after the open enrollment period?

You cannot make changes to your policy unless you have a qualifying event. You will not be able to make changes to your health insurance plan for the next year after you enroll during the open enrollment period. The only way you can make changes is if a life event arises that makes you eligible for the special open enrollment period.

 

What events qualify?

The standards that determine whether an event qualifies are generally the same everywhere. Special enrollment provisions are found in several places, either in the Health Insurance Portability and Accountability Act (HIPAA), sections 125 of the Internal Revenue Code (IRC, its acronym in English ) ), IRC section 9801 , and the special enrollment period section of the Affordable Care Act (ACA).

There are two classes of EPS triggers:

  • Stop qualifying for health coverage
  • certain life events

Major life events leading to a SEP include: marriage, birth or adoption, death of spouse or dependent, job loss, job change, retirement, reduction in work hours, and relocation. In New York, pregnant women will be able to add or change coverage, but New York is the only state that offers such an option.

Some life events do not qualify for a special enrollment period, such as promotion or demotion without variation in salary; paid or unpaid leave outside the parameters of the Family Medical Leave Act; and changes in childcare expenses.

Most events result in a special enrollment period whether you have a Marketplace plan, an individual plan, or through work; however, that is not always the case. According to the Kaiser Family Foundation, some events only qualify you for a special enrollment period within the Marketplace and not for those outside of the Marketplace. These exceptions are situations related to citizenship, if the person is Native American and with exceptional circumstances.

In addition, any changes you make to your health plan after a qualifying event must be related to that qualifying event. For example, if you get married, you can cancel your health insurance, but only if you join your spouse's health plan. See the chart below for a complete description of qualifying life events.

QUALIFYING EVENT

OPTIONS

 

FAMILY SIZE CHANGE

 

Marriage
  • You will be able to sign up for new coverage for yourself and/or your spouse.
  • You may change your coverage to add new dependents.
  • You may drop coverage if you get coverage through your spouse's plan.

 

dissolution of marriage

(includes divorce, annulment and legal separation)
  • You will be able to sign up for new coverage if you lost your coverage because of the separation.
  • You may change coverage if your dependents lost coverage because of the separation.
  • You will need to remove your ex-spouse from your policy.
  • You may not remove dependents under your policy unless they obtain coverage through your ex-spouse's policy.

 

death of spouse
  • You may remove your spouse from your coverage.
  • You will be able to sign up for new coverage if death caused you to lose your coverage.
  • You may change your coverage to include dependents who lost coverage due to death.

Birth

Adoption

placement for adoption
  • You may enroll yourself, your spouse, and your dependents.
  • Usted podrá cambiar su plan para que refleje el nuevo tamaño de su familia.
  • Usted podrá cancelar la cobertura si obtiene cobertura por medio del plan de su cónyuge.
  • El recién nacido agregado durante el SEP posee cobertura retroactiva a partir del día del nacimiento.

Embarazo

(solo en Nueva York)
  • Usted podrá inscribirse para recibir una cobertura a partir del primer mes de embarazo.

El dependiente obtiene su propia póliza
  • Usted podrá remover un dependiente de su póliza.

El dependiente deja de reunir los requisitos a partir de los 26 años de edad
  • Usted podrá remover un dependiente de su póliza.

Fallecimiento del dependiente
  • Usted podrá cancelar la inscripción del dependiente fallecido.

 

CAMBIO DEL ESTATUS DEL TRABAJO

 

Cambio de trabajo dentro de la misma organización

(incluye promoción, descenso y transferencia)
  • Usted podrá cambiar de cobertura si en el nuevo puesto su plan actual no se encuentra disponible.

 

Pérdida del trabajo
  • Usted estará asegurado hasta fin de mes.
  • Usted podrá continuar teniendo la cobertura para empleados por medio de COBRA, haciéndose cargo de la misma durante 18 meses.
  • De estar disponible, usted podrá inscribirse en el plan de salud de su cónyuge.

Pérdida de la condición de tiempo completo

(30-39 horas por semana)
  • No se permiten cambios.

Pérdida de la condición de tiempo completo

(20-29 horas por semana)
  • Usted podrá cancelar su cobertura y la de sus familiares.
  • Usted podrá cambiar su cobertura.

 

Pérdida de la condición de tiempo completo

(0-19 horas por semana)
  • Si su empleador no le brinda seguro a los empleados de medio tiempo dentro de este nivel, su cobertura vencerá a fin de mes.
  • Usted podrá continuar teniendo la cobertura para empleados por medio de COBRA haciéndose cargo de la misma durante 18 meses.

Reúne los requisitos para recibir beneficios como nuevo empleado
  • Usted podrá obtener nueva cobertura para usted y los miembros de su familia.

Medio tipo a tiempo completo
  • Usted podrá obtener nueva cobertura para usted y los miembros de su familia.

 

El/La cónyuge pierde el trabajo
  • Usted podrá inscribir a los miembros de su familia que reúnan los requisitos y a usted en un plan, si la pérdida del trabajo produjo que usted y sus dependientes perdieran el seguro.
  • Usted podrá cambiar su plan si está agregando dependientes que perdieron la cobertura.

El/La cónyuge consigue un trabajo
  • Usted podrá cancelar su cobertura si usted o sus dependientes obtienen cobertura bajo el nuevo plan del cónyuge.

 

Cambio de la condición del trabajo de su cónyuge
  • Usted podrá inscribirse en un plan si el cambio originó que usted o sus dependientes perdieran el seguro.
  • Usted podrá agregar dependientes a su plan si el cambió originó que los dependientes perdieran el seguro.
  • Usted podrá agregar o cancelar su plan si dicho cambio hace que el seguro del cónyuge sea una mejor opción para usted y sus dependientes.

 

Jubilación

(sin beneficios médicos para jubilados por parte del ex empleador)
  • La cobertura terminará a fin de mes.
  • En caso de cumplir los requisitos, usted podrá inscribirse en Medicare.
  • Usted podrá continuar teniendo la cobertura para empleados por medio de COBRA haciéndose cargo de la misma durante 18 meses.
  • Usted podrá inscribirse en un plan de seguro médico individual o del Mercado.

El cónyuge pierde la cobertura tradicional o por jubilación
  • Usted podrá agregar a su cónyuge a la cobertura.
  • Usted podrá cambiar su plan de salud.

Comienzo de la licencia sin goce de sueldo

(30+ días)
  • Usted podrá cambiar su cobertura.
  • Usted podrá cancelar su cobertura.

Reincorporación luego de la licencia sin goce de sueldo

(30+ días)
  • Usted podrá cambiar su cobertura.

 

Reincorporación luego de la licencia militar
  • Usted podrá inscribirse e inscribir a su cónyuge y a sus dependientes en su misma cobertura.
  • Usted podrá cambiar su plan de salud.

 

CAMBIO DE RESIDENCIA

 

 

 

Cambio de residencia
  • Usted podrá cancelar su cobertura si con motivo de una mudanza, usted, su cónyuge o dependiente no reúne los requisitos de su seguro.
  • Usted podrá cambiar la cobertura si con motivo de una mudanza usted, su cónyuge o dependiente reúne los requisitos de su seguro.
  • Usted podrá agregar o cambiar la cobertura si con motivo de una mudanza, usted o un dependiente no reúnen los requisitos para recibir el seguro de su cónyuge.

 

REQUISITOS PARA ACCEDER A MEDICARE o MEDICAID

 

Reunir los requisitos para acceder a Medicare o Medicaid
  • Usted podrá cancelar la cobertura privada de la persona que se ha inscripto a Medicare.

Perder los requisitos para acceder a Medicare o Medicaid
  • Usted podrá agregar una cobertura para el familiar afectado.

 

OTRO

 

Orden judicial
  • Usted podrá agregar, cambiar o suspender la cobertura si una orden judicial u otro decreto oficial así lo exigiera.

Cambios importantes de la cobertura
  • Usted podrá cambiar de plan si los servicios se reducen drásticamente; por ejemplo: si una amplia red de salud opta por dejar de aceptar su seguro.

Cambios en su ingreso que afectan a la cobertura para la que usted reúne los requisitos (planes del mercado)
  • Podrá realizar cambios en la cobertura actual de su plan.

Adquiere la ciudadanía de los Estados Unidos

(planes del mercado)
  • Usted podrá inscribirse para recibir una cobertura.

Cesación de encarcelamiento – prisión o cárcel

(plan del mercado o con un asegurador privado)
  • Usted podrá inscribirse para recibir una cobertura.

Sobreviviente de un abuso doméstico/violencia o abandono por parte del cónyuge

(planes del mercado)
  • Inscríbase usted y sus dependientes en su plan de salud, distinto del plan de la persona que haya abusado de usted o lo/la haya abandonado. (Si usted contrajo matrimonio con un/a abusador/a o persona que lo haya abandonado, puede registrarse como “soltero/a” sin recibir una multa por haber declarado incorrectamente su estatus marital).

Ha sufrido una grave enfermedad o desastre natural que impidió que pudiera inscribirse

(planes del mercado)
  • Usted y sus dependientes pueden inscribirse en un plan de salud si una hospitalización, incapacidad cognitiva temporal o desastre natural inesperado impidió que se inscribiera (por ejemplo un terremoto).

 

¿QUÍENES NO NECESITAN CONTAR CON UN ACONTECIMIENTO QUE REÚNA LOS REQUISITOS?

 

Inscripción a Medicaid

 
  • No limited enrollment period. If you qualify, you can apply at any time and coverage will begin immediately.

Enrollment in the Children's Health Insurance Program (CHIP)

 
  • No limited enrollment period. If you qualify, you can apply at any time and coverage will begin immediately.

Native American and Alaskan

(market plans)
  • Under the Native Health Care Improvement Act, Native Americans can enroll at any time of the year.

*Insure.com works to maintain an up-to-date and comprehensive list; however, the special enrollment table may not apply to all plans (especially dental and group life insurance that may be included in your work plan) and individual circumstances should be verified with the administrator. health insurance.

 

Loss of coverage due to job loss

If you lost your health coverage outside of open enrollment because of a job loss, you should have a few options.

You will be able to enroll in your spouse's insurance. Health plans offered through the employer must provide a special enrollment period of at least 30 days. Some plans that offer jobs give you more time, so check with your spouse's health insurance administrator to see how much time your plan gives you to make changes if you qualify for a special enrollment period.

Another option is to purchase an individual health insurance plan through the Marketplace or directly from an insurance company or agent. If your spouse and dependents also lost coverage, you may be able to get a family plan. This gives you an SPE that starts 60 days before and 60 days after the date you lost your coverage, which is beneficial as it allows you to seek coverage if you know ahead of time that you are about to lose your job and health insurance plan. .

You also have the option of keeping your current insurance. Most employers with large numbers of employees offer COBRA, the option to continue under your employer's group plan for at least 18 months. COBRA is expensive, as you continue to pay your portion of the fee, plus the portion your employer was paying, plus administrative costs.

Another option is to enroll in publicly subsidized Medicaid , which is sometimes available when a person's income drops dramatically. Medicaid commonly covers children, the disabled, and other vulnerable groups, but some states have expanded it to cover low-income adults.

 

How do I make a change or get insurance during the special enrollment period?

If you're looking for a Marketplace policy, you can answer a few filter questions to see if you qualify for the special enrollment period. If so, you can make changes or get a policy online or by phone.

The Marketplace requires proof that you qualify for PES, so be prepared to submit documentation to show that you qualify.

If you have health insurance through your employer, you will need to contact your health insurance administrator to let them know about your situation. The administrator should confirm if your situation qualifies you for a special enrollment period and can help you make changes to your policy. Generally, proof of the event is required, be it birth, death, spouse's job loss, etc.

There are time limits on your special enrollment period: with the Marketplace, typically 60 days after the triggering event and typically 30 days for plans offered through a job. It is necessary to act quickly. If you do not apply during this period, you will have to wait until the next open enrollment period.

It is important to provide accurate information when applying for insurance and trying to get a special enrollment period. Any person who intentionally provides false or untrue information will be subject to penalties under Federal Law.

 

When does the change take effect?

Most changes to plans offered through a job take effect on the first day of the month after the event or date you reported the event from which you are requesting coverage or changes. For cancellations, it may be the last day of the month after the event. Changes in the middle of the month are normally made in case of birth or death. Plan rules may vary, so check with your health insurance administrator.

With most Marketplace plans, if you sign up before the 15th of the month, coverage will begin the first day of the next month. However, if you enroll after the birth of your child, coverage may start retroactively from the day the baby was born, even if you don't enroll the baby until 60 days after the birth.

 

Medicare has different rules

Enrollment in Medicare has its own rules. A person is eligible for Medicare starting at age 65, unless the person has been receiving Social Security and disability payments. The Initial Enrollment Period (IEP) is seven months. It begins three months before the month the person seeking to enroll was born, through the month of their 65th birthday, and then continues for three months. Enrollment may be completed at any time within that time.

Every year, there is an open enrollment period, from October 15 to December 7, during which you can make changes to your Medicare plan or to your Medicare drug plan. If you want to make changes outside of the open enrollment period, certain changes in your life or in your coverage will be considered qualifying events and will trigger a special enrollment period. You can find the complete list at

If you didn't apply for Medicare Part A or Part B when you first became eligible, but you enroll later, you will be charged a late enrollment penalty. For Part A, your monthly premium could increase by up to 10 percent. You will have to pay this higher premium for twice as long as the number of years you could have had Part A, which you did not sign up for.

For Part B, if you didn't sign up when you first became eligible, you'll have to wait to sign up until the general enrollment period (January 1 to March 31 and coverage begins July 1) and you'll have to pay a late penalty for as long as you have Part B. Your late enrollment penalty will be up to 10 percent for each 12-month period you may have had Part B that you didn't sign up for.

 

What if I don't want to have insurance?

You do not have to hire it, but you will still have to pay. If you can afford insurance but choose not to, the government will impose a penalty called an "individual shared responsibility payment." This penalty is 2.5 percent of your income or a flat penalty, whichever is greater, and is due at the time you file your federal income tax return. If you are uninsured for three months or more, you will have to pay a penalty for the months that you, your spouse or dependents were uninsured. If you're uninsured for less than three months, you'll be covered during a “short-term” exception and you won't be penalized.

The fine increases rapidly. In 2014 it peaked at $285 per home and in 2015 at $975 per home. In 2016, the maximum penalty was $2,085, the equivalent of the average premium for a bronze level health insurance package through the government insurance marketplace.

 

What if I skipped registration and don't have a qualifying event?

Some health insurance companies offer insurance coverage that can provide protection until the next opportunity arises. You can compare providers and easily buy a health insurance policy. Short-term coverage does not meet the minimum essential coverage requirements mandated by the ACA and you will be penalized if you do not have required coverage for three months or more.

 

What do I need to know before the next enrollment period?

Choosing a health insurance package can be overwhelming, so take time to understand what you're buying, whether it's during the standard enrollment period or during the special enrollment period.

If you have questions about how to find a plan that fits your needs, you may benefit from finding a reputable, licensed insurance agent, or working with one of your state's marketplace navigators whose job it is to advise on the right plan. .

Maintaining medical coverage will help you and your dependents save money in the event of a sudden medical emergency or health problems. Understanding when you are eligible to make changes is the key to avoiding mistakes and missed opportunities that can lead to fines, high policy costs or medical bills you may have to pay.