Understanding health insurance special enrollment periods

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Insights:

If you qualify, you can sign up for most health insurance plans during initial enrollment, open enrollment or a special enrollment period.

People can sign up for health insurance during the open enrollment period or when they first become eligible for coverage, such as starting a new job. You can also sign up and make changes to your health coverage if you have a qualifying event, such as losing other coverage, a spouse’s death, getting married or having a child.

Key Takeaways

Open enrollment is a time to sign up for health insurance or make changes to your coverage.ACA marketplace, employer and Medicare plans have their own open enrollment periods.
You can also sign up for coverage during your initial enrollment period, such as after becoming eligible for coverage with a new job.
To qualify for a special enrollment period, you must have a qualifying event, such as having a child, getting married or losing your health coverage.
Some types of coverage, such as Medicaid, don’t have open enrollment periods, so you can sign up any time if you’re eligible.

Here’s what you need to know about when you can enroll in health insurance.

When is open enrollment for 2023?

If you’re getting a plan from the marketplace, the open enrollment period for the health insurance marketplace begins on November 1st, 2022. In most states, it ends on December 15th, 2022, but the date may vary for some states.

However, employers create their own open enrollment window. These are periods either once or twice per year.

Meanwhile, Medicare has three periods for enrollment:

When you become eligible for Medicare, you can join a Medicare plan no matter what month or day it is.
After your initial eligibility, you can join Medicare during the open enrollment period, which is from October 15th to December 7th.
If you’re switching from one Medicare Advantage Plan to another, you can enroll in your new plan from January 1st to March 31st.

What is an open enrollment period?

Open enrollment when you can make changes to your health insurance plan. You can also sign up for a new plan during open enrollment.

You’re able to enroll in a plan through:

Your employer
An individual health plan through your state’s or the federal government-run insurance marketplace or directly through an insurance company
Medicare

During the annual open enrollment period, you can change your current plan or obtain new coverage. It’s important to make these choices carefully, says Gretchen Jacobson, vice president, Medicare, for The Commonwealth Fund.

“The best plan for your friend may not be the best plan for you,” she says. “Each plan has different benefits, different drug coverage and different health care providers in their networks.”

Selecting the right health insurance plan can be challenging. Each year, millions of Americans have the opportunity to choose a new plan, or to tweak their existing coverage. But with so many options available, how can you know if you are making the right choice?

“Get educated,” says Paul Fronstin, director of the health research and education program at the Employee Benefit Research Institute. “There are potentially options out there for you.”

Fronstin adds that such alternatives may or may not be better than the plan you already have. “But that is something you have to figure out,” he says.

How to prepare for open enrollment?

Choosing a health insurance package can be daunting, especially because you don’t know in advance what your expenses will be over the following year.

“You can’t always predict what the best plan’s going to be,” Fronstin says. “The whole point of insurance is to be there for unexpected expenses.”

Take time to understand what you are purchasing, whether during the standard enrollment window or a special enrollment period.

If you have questions about finding the right plan for your needs, you may benefit from finding a reputable, licensed insurance broker or working with one of your state marketplace’s navigators, whose job it is to point people toward workable plans.

However, in the end, remember that it’s often hard to know in advance whether you’re making the right choice. Fronstin offers the example of a young person who is healthy and rarely visits the doctor. Such an individual may try to save money by choosing a cheap plan with a high deductible.

“But that doesn’t mean in hindsight after a year that will have been the best option for you, because maybe you broke your arm riding your bike,” he says.

In the end, even a decision that’s correct at the time you made it might be something you regret later. “That’s the nature of insurance — you’re placing a bet,” Fronstin says. “Sometimes you win and sometimes you lose.”

What is special enrollment?

If you don’t sign up for health insurance during the allocated time, you must wait until the next open enrollment period unless you have a qualifying event that makes you eligible for a special enrollment period (SEP).

If you have a qualifying event, you can purchase health insurance or change your existing coverage without waiting until the next open enrollment. If you don’t have a qualifying event, you’re required to maintain your insurance as is until the following enrollment period.

What is a qualifying event for health insurance?

There are two types of triggers for SEPs:

Loss of eligibility for health coverage
Certain life events

Life events that create a special enrollment period include:

Marriage
Birth or adoption
Death of a spouse or dependent
Job loss
Job change
Retirement
Reduction in work hours
Relocation

Your state may offer additional rules for life events that create an SEP. For example, in New York, women who become pregnant may add or change coverage.

Most qualifying events trigger a special enrollment period whether you have a marketplace plan, individual plan or workplace plan. However, that’s not always the case. According to the Kaiser Family Foundation, some events only qualify you for a special enrollment period in the marketplace and don’t apply to the outside market. The exceptions are situations related to citizenship, native status and exceptional circumstances.

Also, the changes you make to your health plan due to a qualifying life event should be consistent with the event. For example, if you get married, you can drop your health insurance, but only if you’re enrolling in your spouse’s health plan.

QUALIFYING LIFE EVENT	OPTIONS
CHANGE IN FAMILY SIZE
Marriage	You may enroll in new coverage for you and/or your spouse. You may change your coverage to add new dependents. You may cancel coverage if you become covered by your spouse’s plan.
Dissolution of marriage (includes divorce, annulment and legal separation)	You may enroll in new coverage if you lost your coverage in the separation. You may change coverage if your dependents lost coverage in the separation. You must remove your former spouse from your policy. You may not remove dependents from your policy unless they become covered by your former spouse’s policy.
Death of spouse	You may remove your spouse from your coverage. You may enroll in new coverage if the death caused you to lose your coverage. You may change your coverage to include dependents who lost coverage due to the death.
Adoption	You may enroll yourself, your spouse and your dependents. You may change your plan to reflect the new size of your family. You may cancel coverage if you become covered by your spouse’s plan. Newborn added during SEP has coverage from day of birth applied retroactively.
Pregnancy (New York only)	You may enroll in coverage as of the first month of pregnancy.
Dependent moves to own policy	You may remove a dependent from your policy.
Dependent becomes ineligible at age 26	You may remove a dependent from your policy.
Dependent’s death	You may cancel enrollment for the deceased dependent.
CHANGE IN EMPLOYMENT STATUS
Job change within the same organization (includes promotion, demotion and transfer)	You may change coverage if your current plan is no longer available to you in your new position.
Loss of employment	You may continue your employee coverage through COBRA at your own expense for 18 months. You may enroll in your spouse’s health plan, if available.
Loss of full-time status (30-39 hours per week)	No change is permitted.
Loss of full-time status (20-29 hours per week)	You may cancel coverage for yourself and family members. You may change your coverage.
Loss of full-time status (0-19 hours per week)	If your employer doesn’t provide insurance for part-time employees at this level, your coverage will lapse at the end of the month. You may continue your employee coverage through COBRA at your own expense for 18 months.
Newly benefit-eligible	You may obtain new coverage for yourself and for your family members.
Part-time to full-time	You may obtain new coverage for yourself and for your family members.
Spouse loses employment	You may enroll yourself and eligible family members in a plan if the job loss caused you and your dependents to lose insurance. You may change your plan if you’re adding dependents that lost coverage.
Spouse becomes employed	You may cancel your coverage if you or your dependents become covered under the spouse’s new plan.
Spouse’s employment status changes	You may enroll in a plan if the change caused you or your dependents to lose insurance. You may add dependents to your plan if the change caused dependents to lose insurance. You may change or cancel your plan if the change causes the spouse’s insurance to be a better option for you or your dependents.
Retirement (with no retiree health benefits from former employer)	You may enroll in Medicare, if eligible. You may continue your employee coverage through COBRA at your own expense for 18 months. You may enroll in a Medicaid plan if you meet the income requirements. You may enroll in a marketplace or individual health insurance plan.
Spouse loses traditional or retiree coverage	You may add your spouse to your coverage. You may change your health plan.
Begin unpaid leave (30+ days)	You may change your coverage. You may cancel your coverage.
Return from unpaid leave (30+ days)	You may change your coverage.
Return from military leave	You may enroll yourself, spouse and dependents to your coverage. You may change your health plan.
CHANGE IN RESIDENCE
Change of residence	You may cancel coverage if you, your spouse or a dependent has become ineligible for your insurance due to a move. You may change coverage if you, your spouse or a dependent has become eligible for your insurance due to a move. You may add or change coverage if you or a dependent have become ineligible for your spouse’s insurance due to a move.
MEDICARE or MEDICAID ELIGIBILITY
Become eligible for Medicare or Medicaid	You may cancel private coverage for the person who has enrolled in Medicare.
Lose eligibility for Medicare or Medicaid	You may add coverage for the affected family member.
OTHER
Court order	You may add, change or suspend coverage if a court order or other official decree requires it.
Significant coverage changes	You may change plans if services are drastically curtailed; for instance, if a large health network opts to stop accepting your insurance.
Changes in your income that affect the coverage for which you qualify (Marketplace plan)	You may make changes to current coverage plan.
Become a U.S. citizen (Marketplace plan)	You may enroll in coverage.
Leaving incarceration – prison or jail (Marketplace plan or with private insurer)	You may enroll in coverage.
Survivor of domestic abuse/violence or spousal abandonment (Marketplace plan)	Enroll yourself and your dependents in your own health plan separate from your abuser or abandoner. (If you are married to abuser/abandoner, you can list “unmarried” without penalty for mis-stating your marital status.)
Had a serious medical condition or natural disaster that kept you from enrolling (Marketplace plan)	Can enroll you and dependents in health plan if unexpected hospitalization, temporary cognitive disability or natural disaster (e.g. earthquake) kept you from enrolling.
WHO DOESN’T NEED A QUALIFYING EVENT?
Medicaid enrollment	No limited enrollment period. If you qualify, you can apply at any time and coverage will begin immediately.
CHIP (Children’s Health Insurance Program) enrollment	No limited enrollment period. If you qualify, you can apply at any time and coverage will begin immediately.
Indigenous Americans & Alaska Natives (Marketplace plans)	Under the Indian Health Care Improvement Act, Indigenous Americans can enroll anytime during the year.

*Insure.com works to keep an updated and comprehensive list; however, the special enrollment chart may not apply to every benefit plan (especially dental and group life insurance that may be included in your workplace plan) and individual circumstances should be verified with your health insurance administrator.

Sources:

HealthCare.gov. “When can you get health insurance?” Accessed June 2022.

Kaiser Family Foundation. “Summary of the Affordable Care Act.” Accessed June 2022.

Medicare.gov. “Joining a health or drug plan.” Accessed June 2022.

Frequently Asked Questions

If my spouse gets a new job, is that a qualifying event?

Yes, a new job is considered a qualifying event if you lose your health insurance. If a job loss causes your spouse and you to lose coverage, you enter the special enrollment period and can purchase private health insurance.

Is going from part-time to full-time a qualifying event?

Yes. Going from part-time to full-time is considered a qualifying event, and prompts a special enrollment period.

Can I add someone to my health insurance after open enrollment?

You can only add someone to your health insurance after open enrollment if it is prompted by a life-changing event, such as giving birth or adopting a child.

What types of health insurance use open enrollment periods?

Most types of health insurance use open enrollment periods. These include:

Employer-based plans
Individual health plan coverage that you get through a state or federal marketplace or directly through an insurer
Medicare

What types of health insurance don’t use open enrollment?

A handful of health insurance types don’t use open enrollment. They include:

Medicaid
Children’s Health Insurance Program (CHIP) plans
Short-term health insurance

Instead, you can sign up for that coverage, if you’re eligible, any time of the year.

Can I change my plan during special enrollment?

Yes, you can change your plan if you qualify for a special enrollment period. However, your choices may be a bit more limited than during open enrollment. Most people who qualify for an SEP in the ACA marketplace are limited in the number of health plan “metal” categories.

If you want the opportunity to select from all four metal categories, you will need to wait until the next open enrollment period.

What happens if you don’t enroll during open enrollment?

If you don’t enroll during open enrollment, you might end up covered anyway. For example, Fronstin says that if you already have health insurance through an employer but don’t choose coverage the next time open enrollment comes around, typically “you’re automatically re-enrolled in the same plan if you don’t do anything.”

You may also qualify to purchase coverage if you take on a new job that offers health care benefits. Another way to get insurance outside of the open enrollment period is to qualify for a special enrollment period or to qualify for a program such as Medicaid.

However, in other situations, you may not be able to find health insurance coverage until the next open enrollment period.

What qualifies for a special enrollment period?

If you experience a qualifying event, you may be eligible for a special enrollment period (SEP) that allows you to get health insurance coverage outside of the normal open enrollment period.

A sudden loss of eligibility for health coverage can trigger an SEP, as can life events, such as:

Marriage
Birth or adoption
Death of a spouse or dependent
Job loss
Job change
Retirement
Reduction in work hours
Relocation

More Resources:

Chris Kissell

Contributing Researcher

Chris Kissell is a Denver-based writer and editor with work featured on U.S. News & World Report, MSN Money, Fox Business, Forbes, Yahoo Finance, Money Talks News and more.