The difference between Open Enrollment and Special Enrollment

Open Enrollment is the yearly window – typically in the fall – where individuals and families can sign up for health insurance, maintain their current plan, adjust it, cancel it, or find a new one that fits their health care needs. 

The Open Enrollment Period is limited to a few weeks. If you miss it, you will most likely have to wait until the next period the following year. However, you may qualify for a Special Enrollment if you recently experienced a major life event, which is a time when you can enroll or change your health insurance outside the normal Open Enrollment Period. Additionally, you may qualify for a Special Enrollment Period (SEP) if your household income is below 150% of the federal poverty level (FPL). allows you to enroll in health insurance outside of the Open Enrollment Period.

While most Americans are familiar with Open Enrollment, few know about the Special Enrollment Periods.

What Are the Different Open Enrollment Periods?

Most Americans must sign up, modify, or cancel their health insurance during the Open Enrollment Period. If your health insurance is through your work, Medicare, or the Affordable Care Act (ACA) marketplace, you will have an Open Enrollment Period. 

The reason for the limited enrollment time frames each year is to prevent people from gaming the system by signing up for insurance when they get sick, which would unfairly drive up rates for everyone. 

Here are the important Open Enrollment dates:

• ACA Marketplace Plans: In most states, individuals and families can enroll between November 1 and January 15. 
• Job-Based Plans: Your employer sets the enrollment period. Typically, job-based plan enrollment is during the fall, but may happen anytime.
• Medicare: The enrollment period is between October 15 and December 7 every year.

Some insurance plans have no set Enrollment Period, meaning you can enroll anytime throughout the year.

• Medicaid
• Children’s Health Insurance Program (CHIP)
• Dual Eligible Special Needs Plans (DSNP)

What Qualifies Someone for a Special Enrollment Period?  

If you miss the yearly Open Enrollment Period to sign up for health insurance, you may still qualify for a Special Enrollment Period if you recently experienced certain life events. Note that depending on your Special Enrollment Period, you could have 60 days before or 60 days after the event to enroll in a plan. 

Here are some life events that may allow you to qualify for a Special Enrollment period:

• Household Changes: If, in the past 60 days, you got married, divorced had a baby, adopted a child, or had someone oin your Marketplace plan die, you may qualify for a Special Enrollment Period.
• Residence Changes: If you moved to a home in a new ZIP code or county or from a foreign country or US territory, you may qualify for a Special Enrollment Period. However, you must demonstrate qualifying health coverage for one or more days during the 60 days before changing residence unless you are moving from a foreign country or US territory. 
• Loss of Health Coverage: If you or anyone in your household lost qualifying health coverage in the past 60 days or will lose coverage in the next 60 days, you may qualify for a Special Enrollment Period. Note: details will vary based on the coverage lost (e.g., job-based, individual, Medicaid, etc.)

Other life events that may qualify you for a Special Enrollment Period include becoming a dependent due to a court order or if your household income is below a certain amount. 

Planning for Open Enrollment Doesn’t Have to Be a Hassle

Preparing for Open Enrollment doesn’t have to be a burden or intimidating. We can explainthe nuances of Open Enrollment versus Special Enrollment. Contact Antidote Health today to learn how we can help.