As a health insurance agent since the dawn of the Affordable Care Act, I often receive the question: You mean I can’t just sign up for health insurance any time of year?! And unfortunately, my answer is: “Yes, with exceptions.” So what are those exceptions anyway?

Oftentimes some people are keenly aware of such exceptions simply because of their life situation, such as a major move. Once they leave the service area of their old health insurance plan, individuals and families often realize, upon arriving in their new town, that their health insurance no longer works there. This is what I, as an insurance agent, hope prompts a call to a licensed agent at a local independent agency. This is because an agent at an independent agency can shop most every plan in the new area and will be able to not only assist a person or family with the transition onto new insurance, but the agent will also have a very good idea of which companies sell plans in their new area, and which plans are the most affordable with benefits that are well-structured. 

Exceptions to the normal open enrollment period (which occurs in the fall) are called “special enrollment periods” and are caused by “qualifying events.” These exceptions are “special” because it allows people to get coverage at odd times of year, outside of the normal open enrollment period. As an insurance agent and a fellow human being, I think these events are “special” because it usually means a major, oftentimes exciting change in someone’s life. These changes can include: getting married, having a baby, moving to a new town, switching jobs (and needing new health coverage), adopting a child, a loss of state Medicaid coverage (usually due to an increase in household income), or becoming an “adult” at age 26 and coming off of your parents’ plan.

Unfortunately, not all qualifying events are positive. Special circumstances that are not easy to deal with can be made less stressful by working with an insurance agent. Situations like a divorce, a job loss (in tandem with a loss of health coverage), and a death of a family member in the household are already grueling enough, but to add insult to injury, a loss of coverage or a change in the household’s coverage oftentimes occurs simultaneously. Having an agent who is a professional and can explain in plain language what a person’s next health insurance options are makes for a much easier transition, especially at times when the applicant has major life stresses occurring.

Some special events are unlikely or unusual, such as a health plan completely ending in a certain service area or an insurance company becoming finically insolvent and all members then needing a new plan. Other odd qualifying events have to do with a person not being able to seek out health insurance during the open enrollment period due things like: enduring a natural disaster, being hospitalized during the enrollment period, being a victim of domestic violence, or having experienced technical errors that can sometimes occur when filling out a health insurance application online through state and federal exchange websites such as Covered California or Healthcare.gov.

The special enrollment period that occurs due to these types of qualifying events extends for 60 days from the date of the occurrence (such as the date of a baby’s birth or the date of a marriage certificate). If the person or family that are in the special situation do not initiate their change of coverage within that 60-day time period, the difficult part is that they would then have to wait until the open enrollment period occurring in the fall in order to choose a new plan (a plan that starts on the first of the following year). 

This is why I feel that as an insurance agent, it is my duty to speak up and inform the general public about such qualifying events. They are an opportunity to get new health insurance in the 60-day period of time immediately following the life event. One would think that the federal and state exchanges that facilitate the dispersal of tax credits, in addition to the insurance companies themselves, would spend massive amounts of marketing funds and time announcing such special enrollment situations and inform and educate the population. Unfortunately, I have found that if an individual or family hasn’t had to learn the new rules of the ACA, perhaps due to having employer coverage for many years, never having coverage in previous years, just moving back into the United States, or being on state Medicaid for many years, the new rules of the ACA can come as quite a shock—especially if someone has had a qualifying event but let the 60-day special enrollment period pass by.

As far as a solution to this lack of general knowledge about new health insurance rules, I can only say that I hope state and federal exchanges, in addition to health insurance companies themselves, plus health insurance ombudsmen and agents like myself, should continue to shout this information to the masses, so that opportunities for new coverage are not lost, people feel empowered with information that will allow them to change insurances at poignant times, and I don’t get so many shocked callers on the other end of the line that I have to disappoint by telling them that if they don’t have a qualifying event occurring in the last 60 days, I cannot help them obtain new health insurance coverage. That’s the last thing an agent and a compassionate human being wants to say to a hopeful caller. 

For further questions about your personal situation and a potential qualifying event that may be occurring in your life now or in the near future, reach out to your local independent insurance agency and utilize the assistance of a professional, licensed, knowledgeable agent.

 

 

 

~Lindsay Gerken

Life & Health Insurance Agent
Rouge Valley, Oregon

541-500-7736