Orlando Harmon
Special circumstances for insurance are situations that allow a person to enrol in or change their insurance coverage outside of the standard open enrolment period. These circumstances are typically related to significant life events or changes in a person's situation, such as losing existing health insurance coverage, moving to a new state, getting married or divorced, having a baby, or experiencing a natural disaster. Special circumstances can also include errors or delays in enrolment, domestic violence or spousal abandonment, and regulatory changes that impact a person's health coverage. These circumstances are evaluated on a case-by-case basis and may vary depending on location and year.
| Characteristics | Values |
|---|---|
| Loss of health coverage | Involuntary loss of coverage, becoming a dependent or gaining a dependent, divorce, becoming a US citizen or lawfully present resident, an error or problem with enrollment, employer-sponsored plan becomes unaffordable or stops providing minimum value, aging out of a parent's plan |
| Offer of new health benefit | Gaining access to a QSEHRA or Individual Coverage HRA |
| Changes in household | Becoming or gaining a dependent, divorce or legal separation, death of a family member, domestic abuse, pregnancy (in some states) |
| Changes in residence | Moving to a new state or zip code, moving to or from school, seasonal work relocation |
What You'll Learn
Loss of health coverage
Losing your health insurance coverage is a qualifying life event that triggers a Special Enrollment Period (SEP) for a new health plan. This applies to both involuntary and voluntary loss of coverage.
Involuntary Loss of Coverage
An involuntary loss of health coverage is when you lose your coverage for reasons beyond your control. This could include situations such as losing your job and, as a result, your health insurance, or the death of a family member who was the primary holder of the health insurance policy. In these cases, you are eligible for an SEP in the individual market.
It's important to note that loss of coverage due to rescission or cancellation by the insurer does not count as a qualifying life event.
Voluntary Loss of Coverage
A voluntary loss of health coverage is when you choose to leave your job and, consequently, lose your health insurance. This is still considered an involuntary loss of coverage and makes you eligible for an SEP.
However, if you voluntarily drop your coverage by not paying your premiums or choosing to drop off a parent or guardian's plan, you will not qualify for an SEP.
Medicaid Coverage Ending
If you lose your Medicaid coverage due to income changes, age, or other qualifying circumstances, you may be eligible for an SEP. You can contact your state's Medicaid office for more information.
Timing of Special Enrollment Period
The timing of your SEP will depend on the circumstances of your loss of coverage. In most cases, you will have a 60-day window before and/or after the qualifying life event to enroll in a new health plan. However, this may vary depending on your state and the specific situation.
Proof of Loss of Coverage
In some cases, you may be required to provide proof of your loss of coverage to be eligible for an SEP. This is especially true for loss of coverage due to involuntary reasons, as this is the most common qualifying life event.
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Changes in household
Adding or Removing Household Members
Gaining or losing a dependent can trigger a special enrollment period and affect the coverage and savings you are eligible for. This includes placing a child for adoption or foster care, a child on your insurance plan turning 26, or other changes in dependent status. It is important to update your insurance application to reflect these changes.
Moving to a New Permanent Address
Relocating to a new permanent address, especially in a different state, can impact your insurance options. In most cases, moving within the same state will require updating your existing application, while moving to a different state will necessitate starting a new application. This is because insurance plans and coverage options can vary by state.
Changes in Income
An increase or decrease in income can affect your eligibility for savings or the amount you pay for health insurance. It is important to report changes in income promptly to ensure you are receiving the correct coverage and savings options. Additionally, income changes may impact your eligibility for certain insurance programs, such as Medicaid or the Children's Health Insurance Program (CHIP).
Changes in Health Coverage
Changes in health coverage for anyone in your household should also be reported. This includes gaining or losing job-based insurance, receiving coverage from a public program like Medicaid or CHIP, or losing existing coverage. These changes can impact your existing insurance plan and the savings you qualify for.
It is important to note that the specific changes in household that are considered special circumstances for insurance may vary depending on your location and the insurance provider. Be sure to review your insurance plan and consult with your insurance provider to understand how changes in your household may impact your coverage and what specific circumstances qualify for special enrollment periods.
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Changes in residence
If you are moving within the same state, you should still update your insurance provider with your new address, as your insurance rates may be influenced by local crime rates, traffic, population, and the number of uninsured drivers in your area. Moving from a rural area to a densely populated city will likely cause your insurance rates to increase.
If you are moving to a different state, you will need to start a new insurance application and enroll in a plan in your new state. It is important to do this immediately to avoid a break in coverage and to prevent paying for coverage that does not apply in your new state. Do not cancel your current insurance before moving and getting a new policy, as driving without insurance is illegal and can lead to financial consequences if you are in an accident.
In addition to health insurance, you may also need to consider updating your auto insurance and homeowner's insurance when changing your residence.
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Pregnancy and childbirth
Insurance Options for Pregnant Women
Pregnant women have several options for insurance coverage. These include:
- Marketplace health plans: All Marketplace plans cover pregnancy and childbirth, even if the pregnancy begins before coverage starts.
- Medicaid: Medicaid and the Children's Health Insurance Program (CHIP) provide free or low-cost health coverage to millions of Americans, including pregnant women, low-income people, families, and children. Eligibility for these programs depends on household size, income, and citizenship or immigration status, and specific rules and benefits vary by state.
- Short-term disability insurance: This type of coverage can help offset the cost of pregnancy and birth by providing income during pregnancy and after delivery.
- Hospital indemnity plans: These plans can help prepare for the cost of labour and delivery, and can also cover long-term hospital stays, such as in the case of an ICU or NICU admission.
- Government-sponsored healthcare programs: Pregnant women may be eligible for coverage through government-sponsored programs like Medicaid.
- Discount plans: Discount plans are available year-round and offer discounts on certain health care services, prescriptions, and medical devices.
- Individual health insurance policies: These can be purchased directly from private insurance companies or healthcare marketplaces.
Costs Covered by Insurance
Insurance coverage for pregnancy and childbirth typically includes:
- Prenatal care
- Inpatient services (e.g., hospitalization, physician fees)
- Postnatal care
- Newborn care
- Lactation counselling and devices
Costs Not Covered by Insurance
Out-of-pocket costs for pregnancy and childbirth can vary depending on factors such as the type of insurance plan, deductibles, copayments, and choice of provider. Additionally, insurance may not cover:
- Prenatal testing (e.g., ultrasounds, amniocentesis, genetic testing)
- Non-traditional deliveries (e.g., home births with a midwife may be considered 'not medically appropriate' by some insurers)
- Private rooms during hospital delivery
Planning for Costs
To plan for the costs of pregnancy and childbirth, it is important to review the Summary of Benefits and Coverage documents provided by insurance companies. These documents detail how each specific plan covers the cost of pregnancy and childbirth, including any out-of-pocket expenses. Additionally, hospitals may offer lower rates or payment plans for those who are medically needy or who pay in cash.
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Natural disasters
Homeowners' insurance typically covers a wide range of potential disasters, including wind and rainstorms, snow, fire, tornadoes, wildfires, volcanic eruptions, and blizzards. However, it is important to note that common natural disasters like floods and earthquakes are often not covered by standard policies, and separate policies are usually required for these hazards. Additionally, homeowners in coastal areas may need a separate policy for wind or hurricane coverage.
In the United States, flood insurance can be obtained through the National Flood Insurance Program (NFIP) or from a few private insurers, while earthquake coverage is available from most insurance companies as a separate policy or an endorsement to your existing policy.
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Frequently asked questions
A special enrollment period is a window of time outside the normal open enrollment period during which you can make changes to your health insurance plan. This is usually triggered by a major life change or a qualifying life event.
Qualifying life events include loss of health coverage, changes in household composition (marriage, birth, adoption, divorce, etc.), changes in residence, gaining or losing dependent status, and changes in income or eligibility for subsidies.
Typically, you will have a 60-day special enrollment period after the qualifying life event to enroll in a new health plan through federal or state-based marketplaces.
If you miss the deadline, you will likely have to wait until the next open enrollment period to make changes to your health insurance coverage. However, you may be able to submit an appeal within 90 days of the deadline and request an extension.
Yes, survivors of domestic abuse or spousal abandonment are eligible to enroll in a separate health plan from their abuser or spouse. Additionally, natural disasters or political/regulatory changes that impact a large number of people may trigger a special enrollment period.
