Enrollment Periods: Individuals & Families

All the details you need on when you can choose a health plan for yourself and your family: Open Enrollment, Special Enrollment Period, Qualifying Life event.

1211228531

Open Enrollment is a time period every year when individuals and families can enroll in health insurance or change their coverage. Open Enrollment usually starts on November 1st and ends on January 31st ; if you are not able to complete your enrollment during that time, you might still be able to get coverage, if you meet the conditions for a Special Enrollment Period.

Outside of the yearly Open Enrollment Period, there are major life changes or special circumstances that enable you to be eligible for a Special Enrollment Period (SEP). The SEP provides a 60-day window when you can enroll or change your health plan. If you miss that window, you may have to wait until the next Open Enrollment period for a chance to apply for coverage. If you are losing coverage, you can apply for a new plan as early as 60 days before your current insurance will end to avoid a potential gap in coverage.

 

If you experience a major change in your life, it could affect your coverage; these changes may include: marriage, birth, unemployment…etc., and are usually called Qualifying Life Events (QLE). When applying for coverage with a qualifying life event, you may be required to provide supporting documentation for your event; for example, a copy of your marriage certificate would be required when adding a spouse to your plan. There are different types of qualifying life events requiring different types of supporting documentation; continue below to learn more.

Types of Qualifying Events

  • Loss of eligibility for Medicaid, Medicare, or CHIP
  • Loss of Employer Group Coverage
    • Employee is no longer eligible due to termination, a reduction of hours, or end of Cobra coverage.
    • A dependent loses coverage due to the passing of the subscriber (covered employee).
    • Employee becomes eligible for Medicare.
    • Employer no longer offers health coverage.
  • For individuals who have lost their coverage for reasons other than:
    • failure to pay their monthly premiums
    • providing false information on a previous enrollment
    • voluntarily ending their coverage

Minimum Essential Coverage refers to any insurance plan that provides essential health benefits, has standard limits on cost-sharing (like deductibles, copayments, and out-of-pocket maximum amounts), and meets other requirements under the Affordable Care Act. Examples of plans that qualify include: Marketplace plans, job-based plans, Medicare, Medicaid, and Children's Health Insurance Program (CHIP).

Supporting Documentation: Choose the specific document that applies to you from the list below.

  • Signed letter from the previous insurer or employer on company letterhead stating why you lost your coverage.
  • COBRA eligibility letter on company letterhead.
  • Copy of the subscriber’s death certificate.
  • For Medicare eligibility: Copy of letter from CMS stating that you are eligible for Medicare.
  • Signed Letter from employer on company letterhead stating they no longer offer coverage as of a specific date.
  • Signed letter from the administrator (insurance carrier) stating that COBRA benefit has been fully exhausted.
  • Marriage – adding a spouse or partner.
  • Adding a dependent through childbirth, adoption, foster care, or court order (including child support).
  • End of dependent status due to age (dependent turned 26 and no longer qualifies under parent’s coverage), divorce, or legal separation.

Supporting Documentation: Choose the specific document that applies to you from the list below.

  • Copy of the marriage certificate.
  • Copy of the birth certificate, court document, or court order.
  • Copy of the divorce decree or legal separation court order.
  • Letter from employer or previous insurer stating loss of dependent status.
  • Moving to a different state, city, ZIP code or county.
  • Moving into EmblemHealth’s service area.
  • Moving to or from a shelter, or other transitional housing.

Supporting Documentation:

  • Signed letter from the administrator of previous insurer AND the official change of address confirmation letter from the post office, a utility bill, or a credit card statement, showing your new address.
  • Change in your income that impact the coverage you qualify for.
  • Eligibility for advanced premium tax credits (APTC) or cost sharing reductions.
  • Eligibility through citizenship or lawfully present status.
  • Gaining membership in a federally recognized tribe or status as an Alaska Native Claims Settlement Act (ANCSA) Corporation shareholder.
  • Leaving incarceration (released from jail or prison).
  • AmeriCorps member starting or ending your service.
  • Error in enrollment.
  • You are a victim of domestic abuse or spousal abandonment.
  • You are a victim of a natural disaster or you’ve experienced an exceptional circumstance, such as being incapacitated.
  • Your previous or current plan/insurer violated a material provision of your enrollment contract.
  • Pregnancy – up to 30 days after its commencement as certified by a licensed health care provider.

Supporting Documentation:

  • Copy of legal incarceration release letter.
  • For Pregnancy: Written certification up to 30 days after the commencement of the pregnancy, by a licensed health care provider.
  • Letter from the other carrier stating the details of the provision violation of your enrollment contract.
  • Signed letter on company letterhead from the entity (employer, previous insurance carrier or Marketplace) that committed the enrollment error.
  • Copy of the eligibility determination from the State Exchange.

If you have any questions, or you’re not sure which option applies to you, call us at 877-411-3625. A representative will be happy to assist you.