Special Open Enrollment Rules Tighten Up

For individuals who purchase their own health insurance, whether from a state exchange, the federal on­-exchange marketplace or the private off­-exchange marketplace, the regular enrollment period is open for several months at the end of each year to give consumers the opportunity to review their current coverage, shop and compare existing coverage with other plans on the marketplace, and change their insurance coverage to increase the richness of their benefits, or buy-down to save money on monthly premium costs.

Outside of the regular open enrollment period there are more than 30 “life circumstances” that allow individuals and families to change their health insurance coverage, or sign up for a new health plan under a special open enrollment period. Common reasons include loss of insurance coverage, loss of Medicaid eligibility, getting married, having a baby, turning 26 and no longer being eligible for insurance on a parent’s plan or moving to a new state.

However, in 2016 the Centers for Medicare and Medicaid Services (CMS) agreed to tighten rules on who could apply for insurance under the special open enrollment period after health insurance companies complained too many people were enrolling during the off-­season once they realized they needed medical treatment and were uninsured. Of the 30­plus circumstances that allow an individuals to qualify for special enrollment, six were struck from the rule book as of January 1, 2016.

Here are the six life circumstances that CMS has concluded are no longer eligible for a special open enrollment period:

  • Consumers who suffered a system error due to a duplication of the premium tax credit. The system issue has been identified and corrected.
  • Consumers who were affected by a system error because of Social Security Income for all tax dependents, which has since been corrected.
  • Lawful non­-citizens who experienced a system error when determining their monthly payments of the tax credit. The error has been fixed.
  • Lawful non­-citizens with incomes below 100% of the federal poverty limit who had processing delays after they were denied Medicaid eligibility.
  • Consumers who were eligible for or enrolled in COBRA and not sufficiently informed about their coverage options.
  • Consumers who had been enrolled in the Pre­-Existing Condition Health Insurance Program, which has expired.

There has also been clarification on the special enrollment rules for those moving to a new location. Moving to a new state or region still qualifies for the special enrollment period, however, health plan availability must be different than what the policyholder currently has access to. An individual might move 100 miles away, but if the health insurance plans available in their new ZIP code are the same plans they can currently purchase, they do not qualify to change their insurance coverage under the special open enrollment period. The special enrollment period is also not meant for individuals and families moving to a new location temporarily, but must include those who plan to become permanent residents in a new location.

A spokeswoman for the trade group America’s Health Insurance Plans, welcomed the administration’s steps but doesn’t believe the changes go far enough. “While this is an important first step, more needs to be done to validate special enrollment requests.”

If you have questions about whether your or your family qualify for the special open enrollment period, visit