Handbook / Health coverage

Special Enrollment Period: getting Marketplace coverage mid-year

Many people leave a job to work for themselves at a time that has nothing to do with the health insurance calendar. The Marketplace's Special Enrollment Periods exist for exactly that situation. Understanding the rules, and especially the deadlines, helps you avoid a gap in coverage or waiting months for the next Open Enrollment.

Open Enrollment versus Special Enrollment

HealthCare.gov explains that the Open Enrollment Period runs from November 1 to January 15 each year. Outside it, you can only enroll in or change Marketplace plans if you qualify for a Special Enrollment Period, a period of time when you can enroll based on certain life changes. States running their own marketplaces may set different dates, so check your state's site.

Qualifying life events

HealthCare.gov groups the main qualifying events:

Loss of health coverage. You may qualify if you or anyone in your household lost qualifying health coverage in the past 60 days or expects to lose coverage in the next 60 days. That includes losing coverage through your employer, COBRA or a family member's employer plan.

Changes in household. Getting married, having a baby, adopting or placing a child for foster care, or divorce or legal separation that causes a loss of coverage, within the past 60 days.

Changes in residence. Moving to a new home in a new ZIP code or county, moving to the US from abroad, and some other moves. HealthCare.gov notes that moving only for medical treatment or staying somewhere for vacation doesn't qualify.

Other situations may also apply; HealthCare.gov has a tool to check.

Leaving a job to work for yourself

Losing job-based coverage when you leave is a common qualifying event. Practical steps:

1. Find out exactly when your employer coverage ends. It may be your last day or the end of that month.
2. Apply before it ends if you can. Because you may qualify if you expect to lose coverage in the next 60 days, applying early can avoid a gap.
3. Compare with COBRA. See COBRA vs Marketplace.

COBRA and the Special Enrollment Period

HealthCare.gov explains that when COBRA coverage ends, you have 60 days to enroll in a Marketplace plan through a Special Enrollment Period. This applies when COBRA expires or is no longer available, not if you voluntarily cancel it. If you leave COBRA before 18 months:

• losing coverage involuntarily, such as your employer stopping coverage, qualifies
• voluntarily dropping COBRA does not
• choosing to stop paying COBRA premiums on your own does not

That makes the initial choice important. If you choose COBRA, you may be committing to it until the next Open Enrollment.

Documents

HealthCare.gov warns that if you don't provide acceptable documents about losing coverage, you won't qualify for the Special Enrollment Period. Keep:

• a letter from your employer or insurer showing the coverage end date
• COBRA notices
• proof of a move, marriage or birth, as relevant

Send documents promptly when asked.

When coverage starts

Start dates depend on the event and when you pick a plan. For marriage, HealthCare.gov says that if you pick a plan by the last day of the month, coverage can start the first day of the next month. For a birth or adoption, coverage can start on the day of the event even if you enroll up to 60 days afterward. Check the start date shown when you enroll.

Estimating income for savings

When you apply, you estimate your household income for the year. For self-employed people, that means expected business income after expenses. Your estimate determines advance premium tax credits, which are reconciled on your tax return. See estimating income for the Marketplace and the IRS overview of the premium tax credit.

If you miss the window

You generally need to wait for the next Open Enrollment, unless another qualifying event occurs. In the meantime, check whether you could join a spouse's plan, or whether you qualify for Medicaid or CHIP.

A simple checklist

• coverage end date confirmed
• Marketplace application started within 60 days
• income estimate prepared
• documents ready
• plan picked and first premium paid

Outside Open Enrollment, you need a Special Enrollment Period: losing job-based coverage qualifies within 60 days before or after, voluntarily dropping COBRA does not, so apply early, keep documents and estimate your self-employed income carefully.