Many of us are stumped as we call to purchase health coverage and are turned down being told that open enrollment is closed until November or coverage in January. The key to remaining ahead in the ever-evolving world of healthcare is to know what your options are.

If you would like to get a new plan and can’t wait until November, you may fall into two eligible categories to get health coverage; meeting one of the qualifying circumstances, or you can get coverage through a business group.

I’ll explain…

Why Can’t I Purchase a Plan Now?

According to The Affordable Care Act (ACA) healthcare reform is that unless you’re purchasing coverage as part of an employer based/business group, you can only purchase a new plan, or switch plans, during the “Open Enrollment” period between November 15th and February 15th.

The rest of the year – as in now – you must remain with your existing coverage regardless of: how healthy you are; you’re looking at higher or lower level coverage; you’re purchasing on the private market or ACA healthcare exchanges; or that how high of a premium you’re willing to pay out of pocket.

That’s quite daunting, but there’s more to the story.

For starters, understanding the provision to coverage and pre-existing conditions is imperative. Previously, insurers were able to deny coverage to individuals who were at a lapse of coverage within a 12-month period and developed a health condition within that time frame. ACA removed that leverage from insurers, making it possible for people to obtain the health coverage they need regardless of their state of health.

However, insurers didn’t take this casually. Stratospheric premium increases would ensure that people would just remain uninsured—even with a penalty—or purchase a low level of coverage when they’re healthy, and just get onto a quality plan on demand if they get sick or injured. No one in their right mind would purchase quality coverage.

So, nowadays, insurers are only permitted to accept new enrollees during the “Open Enrollment” period preceding coverage.

It is therefore advisable to obtain adequate coverage during the open enrollment period, so that you’re insured if need be when enrollment is closed. Fortunately, the subsidies that ACA offers to those earning below 400 percent of the poverty level makes basic coverage a lot more affordable than before, especially for those toward the lower end of the income spectrum.

If you didn’t make the wisest choice back then, or if you lost that coverage, read on.

Who Could Purchase a Plan Even During Closed Enrollment?

Don’t panic just yet! You may fall under a special category in which open enrollment is not relevant to you.

Here’s what you need to know:

An individual who is part of a group, as in a business, is permitted to purchase health insurance as open enrollment applies only to the individual market.

Under ACA, the minimum size for a group is two employees, although only one of them needs to actually enroll. (Two-person groups can’t comprise husband and wife.)

If you own or work at a company that qualifies for group coverage, you can purchase coverage under the group plan at any time. However, this year-round enrollment only applies if the group as a whole is purchasing coverage anew. An individual cannot obtain his/her own new coverage after open enrollment even if part of a group.

In addition to having year-round enrollment, group coverage offers many other benefits when compared to the individual market. Coverage options tend to be more comprehensive and less pricey.

Group coverage gets even better when dealing with groups of 6-50, and even more competitive with 50+ employees. For instance, Cosmo Insurance Agency offers unique options for groups of 6-50 employees. They cost approximately 30 percent less than the going rate for that level of coverage. Some of these plans also refund a portion of the premiums that weren’t paid out on behalf of the enrollee during the year. Yes, that’s amazing!

Second, even as an individual you may fall under a list of qualifying events that render one eligible for purchasing a new plan.

Events include but are not limited to:

Your existing coverage is no longer offered by your employer to all employees in a similar classification as you

Your insurance is non-renewable since it is no longer offered by your carrier

Your Medicaid coverage was terminated

You lost your job or are no longer employed enough hours to receive employer benefits

Death of a fellow employee or policyholder

You moved from the region where your existing insurer offers coverage

Coverage for a new family member who was born

Marriage, legal separation or divorce

And more, etc.

In all of these situations, you have up to 60 days from the event to enroll in new coverage. Proper documentation to prove these special circumstances is required.

If you find yourself in a situation where you need to enroll in a new plan, it is crucial that you contact a competent agent who is familiar with the ins and outs of ACA and the insurance market. He or she can help you determine whether you qualify for special enrollment and what documentation you need. They can help you determine your best option under any circumstance.

I look forward to answering any of your questions, as always!

For more information or for a free, no-obligation quote, please call (201) 817-1388 or email [email protected].

By Mark Herschlag

Mark Herschlag is the founder and CEO of Cosmo Insurance Agency, which is based in Ocean County. Cosmo Insurance Agency offers personalized solutions for individuals and businesses looking to obtain health, life, dental, long-term care or disability insurance.