Outside of the open enrollment window, there are very few options for health coverage that can be purchased before November 1 (when the next open enrollment begins in the individual/family market), unless you have a qualifying event.
And as a general rule, plans that can be purchased outside of open enrollment (such as fixed indemnity plans, or health care sharing ministry plans) are not suitable to serve as your only health coverage. Some of them might be a good supplement to a major medical policy, but they cannot be thought of as good coverage on their own. Many of our clients have now found themselves unable to apply for ACA compliant health insurance coverage and asking “What is a qualifying event?” If you have a qualifying event that triggers your own special open enrollment window, you can purchase an ACA-compliant major medical health insurance policy outside of the general open enrollment window.
Open enrollment and qualifying events have been part of the individual/family health insurance market since 2014. But they had already been part of the group (employer-sponsored) market for decades at that point. A lot of the qualifying events in the reformed individual market will seem familiar to those who are used to the group market, but some are specific to the new individual market.
In Colorado, applications completed during a special open enrollment window will generally have a first of the following month effective date. In prior years, most of the special enrollment periods had 15th-of-the-month deadlines, which meant you had to apply by the 15th in order to have coverage start on the first day of the following month. But in most cases, the deadline is now the end of the month.
What is a qualifying event? The following events trigger a special open enrollment window:
- Involuntary loss of other coverage. Note that you cannot simply cancel your old plan or let it lapse by not paying the premium — that is not an involuntary loss of coverage. But you can voluntarily leave your job and thus lose your employer-sponsored health insurance — that does count as involuntary loss of coverage. In order to qualify for a special open enrollment window, the coverage that’s ending must be minimum essential coverage. So for example, if you have a short-term policy that is ending, your loss of coverage does not count as a qualifying event and there’s no special open enrollment. Connect for Health Colorado will allow anyone with individual or employer-sponsored coverage that is ending within the next 60 days to enroll up to 60 days in advance of the termination date in order to avoid a lapse in coverage (but the new coverage can only start on the first of the month following the loss of coverage). There is also a 60-day open enrollment window following the loss of coverage.
- Divorce. If a divorce results in a loss of coverage, you have 60 days during which you can enroll in a new plan under the “Involuntary loss of other coverage” event explained above.
- Becoming a dependent or gaining a dependent as a result of birth, adoption, or placement in foster care. You have 60 days to complete the enrollment, but coverage is retroactively effective as of the date of birth, adoption, or placement in foster care (EDIT, 6/17/2014: Updated regulations (see page 30296) allow parents the option to choose a different effective date). The current regulation states that anyone who “gains a dependent or becomes a dependent” (ie, the parents and the new child) is eligible for a special open enrollment window. But Connect for Health Colorado has said that they will accept an application for the whole family (the Federally Facilitated Marketplace also accepts applications for the entire family).
- Pregnancy. This is a new qualifying event in Colorado, starting in 2024. Pregnancy is not a qualifying event in most states, but Colorado enacted legislation in 2022 that creates a special enrollment period due to pregnancy.
- Marriage. A 60-day open enrollment window is available following a marriage. At least one of the spouses must have had prior minimum essential coverage (i.e. if two uninsured people get married, there is not a special enrollment period).
- Becoming a US citizen, when there is no previous lawfully present immigration status.
- A permanent move to an area where different QHPs are available. Anyone moving into or out of Colorado has access to special open enrollment. But even if you are already a Colorado resident and are moving within the state, you may qualify for special open enrollment. Not all QHPs are available in all areas of the state. Kaiser Permanente, Denver Health Medical Plan (Elevate), and Cigna are examples of plans that are available in some parts of Colorado but not others. If you move within the same zip code, your health plan options will likely stay the same. But if you move across the state, there’s a good chance your move is a qualifying event that triggers a special open enrollment.
- An error or problem with enrollment (or non-enrollment) that was the fault of Connect for Health Colorado, a carrier, or an enrollment assistor. If you experienced a problem with enrollment during regular open enrollment, contact us or Connect for Health Colorado as soon as possible in order to remedy the situation.
- Employer-sponsored coverage becoming unaffordable (by ACA definitions) or cutting benefits to the point that it no longer provides minimum value. The ACA defines “affordable” as not costing more than 9.5% of household income (this percentage is indexed annually; in 2023, it’s 9.12%, and it will drop to 8.39% in 2024). Through 2022, the affordability determination applied to the entire family, although the calculation was made by comparing the cost of employee-only coverage with the household income. As of 2023, that rule changed: The exchange now conducts two affordability determinations — one for the employee and one for the whole family. If the employee’s coverage is considered affordable and family’s is not, the family members might be eligible for subsidies through Connect for Health Colorado. We can help you understand how this would work for your family.
If your employer-sponsored plan becomes unaffordable (due to an increase in the premium or a decrease in your household income), you’ll have a special open enrollment window for 60 days before and after the date that your employer plan renews (or your income declines), so you can purchase a new individual plan with no lapse in coverage if you utilize the advance open enrollment window. - Your health policy renews at a time other than January 1. If you have a non-calendar-year health plan, the end of the plan year is a qualifying event that triggers a special open enrollment window. This is true regardless of whether your health plan is a grandfathered individual market plan (those do not have to follow the calendar year) or an employer-sponsored plan.
- Women who lose access to pregnancy-related Medicaid coverage have the same special open enrollment window for purchasing an ACA-compliant plan as someone who is losing coverage that is considered minimum essential coverage. This is despite the fact that coverage only for pregnancy-related services has been deemed not minimum essential coverage.
Some qualifying events apply only to people who are already enrolled through Connect for Health Colorado:
- If an income change makes you newly eligible (or ineligible) for subsidies, either premium tax credits or cost-sharing subsidies, you’ll qualify for special open enrollment.
- Special open enrollment is available if you’re enrolled in a QHP that “substantially violated a material provision of its contract in relation to the enrollee.” There is an official process for this, and the violation has to be “substantial.”
In some cases, year-round enrollment is available without qualifying events:
- Native Americans and Alaska Natives can enroll anytime during the year and may switch from one plan to another up to once per month.
- Medicaid (Health First Colorado) enrollment is also year-round. If you’re already enrolled in Medicaid and your income increases above the Medicaid eligibility level, you’ll have a special open enrollment window triggered by the “loss of other coverage” event explained above (from March 2020 through March 2023, Medicaid disenrollments were paused nationwide. But eligibility redeterminations and disenrollments resumed in Colorado at the end of May 2023; people who lose Medicaid are eligible for a special enrollment period to sign up for an individual/family plan or to transition to an employer-sponsored plan if it’s available to them).
- Employers can purchase small group plans year-round (employees will be subject to the normal open enrollment rules in the group market; the employer will set an annual enrollment window, and special enrollment periods will be available if employees have qualifying life events).