The annual Open Enrollment deadline is the designated yearly window when individuals can sign up for, renew, or change their standard health coverage through the Health Insurance Marketplace, regulated by the Affordable Care Act (ACA). Missing this deadline does not mean you are without options for the rest of the year. Instead, it requires focusing on alternative enrollment pathways and determining eligibility for exceptions and specific programs that allow coverage outside of the standard period.
Accessing Coverage Through Special Enrollment Periods
The primary path to obtaining ACA marketplace coverage outside Open Enrollment is through a Special Enrollment Period (SEP), triggered by a Qualifying Life Event (QLE). A QLE represents a significant change in life circumstances, ensuring individuals who experience unforeseen changes can still access comprehensive coverage.
Common QLEs include the involuntary loss of minimum essential coverage, such as losing a job-based health plan or COBRA coverage expiring. Marriage, divorce, or legal separation that results in the loss of coverage are also considered QLEs. The birth of a child, adoption, or placement into foster care triggers this special window as well.
A permanent move to a new geographic area that offers different health plan options also qualifies for a SEP, provided you had prior coverage. Changes in income or household size that affect subsidy eligibility can also open this enrollment window. Note that the event must be qualifying, and in some cases, requires that you had minimum essential coverage preceding the QLE. Once a QLE occurs, you typically have a 60-day window to select a new marketplace plan.
Year-Round Enrollment Options: Medicaid and CHIP
For individuals and families with lower incomes, the enrollment window is not restricted to the annual Open Enrollment Period or dependent on a Qualifying Life Event. Medicaid and the Children’s Health Insurance Program (CHIP) both offer year-round enrollment opportunities. These programs provide comprehensive coverage based on income and household size relative to the Federal Poverty Level (FPL).
Medicaid eligibility for adults under age 65 typically extends up to 138% of the FPL in states that have expanded the program. Individuals with incomes below 100% of the FPL who reside in non-expansion states may not qualify for Medicaid but also may not qualify for tax credits on the marketplace. Eligibility is determined using a methodology based on Modified Adjusted Gross Income (MAGI).
CHIP provides coverage for children in families whose incomes are too high for Medicaid but who still struggle to afford private insurance. CHIP income limits vary by state but often extend to 200% of the FPL or higher. Applications for both Medicaid and CHIP can be submitted at any time during the year, and coverage generally begins quickly once eligibility is confirmed.
Temporary and Non-Marketplace Alternatives
If you do not qualify for a Special Enrollment Period or income-based programs like Medicaid, temporary alternatives can bridge a coverage gap, though they carry significant limitations. Short-Term Limited Duration Insurance (STLDI) plans are one option intended for temporary coverage during a transition period. These plans are not regulated by the ACA and do not provide the same consumer protections as marketplace plans.
A major drawback of STLDI plans is that they are not required to cover pre-existing conditions, often leading to denied claims for ongoing health issues. They frequently exclude Essential Health Benefits (EHB), such as maternity care, mental health services, and prescription drug coverage, which are mandatory in ACA-compliant plans. Because these plans often limit annual and lifetime payouts, they should only be considered a stop-gap measure against catastrophic, unexpected medical events.
Other Non-Marketplace Options
Other alternatives include Health Care Sharing Ministries, which are faith-based programs where members share medical costs, but they are not insurance and do not guarantee payment of claims. Catastrophic health plans are another option, but eligibility is typically limited to people under 30 or those with a certified financial hardship exemption. These plans have low premiums but very high deductibles and are generally only useful for major emergencies.
Specific Enrollment Considerations for Medicare and COBRA
Medicare and COBRA have specific enrollment rules that operate independently of the ACA Open Enrollment period.
Medicare Enrollment
For individuals turning 65, the Initial Enrollment Period (IEP) for Medicare Part A and Part B totals seven months, beginning three months before the 65th birthday month and ending three months after it. Missing the IEP without having other creditable coverage, such as through an employer, can result in a significant financial penalty.
If the IEP is missed, individuals must wait for the General Enrollment Period (GEP), which runs from January 1 through March 31, with coverage starting July 1. The penalty for late enrollment in Medicare Part B is a permanent 10% increase to the monthly premium for every full 12-month period enrollment was delayed. This financial consequence underscores the importance of adhering to the IEP if you do not have qualifying employer coverage.
COBRA Continuation Coverage
If the missed Open Enrollment was for employer-sponsored coverage, the Consolidated Omnibus Budget Reconciliation Act (COBRA) provides a temporary continuation of that group health coverage. COBRA applies to most private-sector employers with 20 or more employees and is generally triggered by events like job termination or a reduction in hours. While COBRA allows you to keep your existing plan, the enrollee is typically responsible for the full premium plus an administrative fee of up to 2%, making it a costly, yet comprehensive, temporary option.