What to Do When You Miss Open Enrollment at Work

Open enrollment for healthcare coverage is the period of time when employees can enroll, disenroll, or make changes to their health benefits.

Open enrollment is also available for individuals or families who buy their own individual/family health insurance through the Affordable Care Act (ACA) exchange (Marketplace) or directly from health insurance companies (known as off-exchange).

This article will briefly explain how open enrollment works, as well as what to do if you miss the open enrollment period.

What Is Open Enrollment?

Each year, employers with more than 50 employees that offer health benefits must offer an "open enrollment" period when employees can opt in or out of plans, or make changes to their health benefits. Most small employers also offer an open enrollment period.

Insurance rates are reassessed during this period, and health plan prices are often altered for the coming benefit year.

Typically, the open enrollment period is the only period of time during the year when:

• Changes can be made to an enrollee's coverage
• An eligible individual can enroll

The exception to this rule is when the enrollee or eligible individual experiences a qualifying event.

For employer-sponsored plans, open enrollment is also the only time that coverage can be dropped without a qualifying event. But coverage purchased in the individual/family market (on-exchange or off-exchange) can be dropped at any time, without the need for a qualifying event.

When Is the Open Enrollment Period?

If you get your health benefits through your job, your annual open enrollment period may last for only a week or two, and typically isn't more than a month long. There are no rules in terms of how long an employer's open enrollment period has to be.

Employers often schedule their open enrollment period in the fall, with the new plan year starting on January 1. However, employers have flexibility in terms of scheduling open enrollment and their plan year, so it doesn't have to correspond with the calendar year.

In other words, your employer's plan year might run from July through June, with open enrollment in the spring and your enrollment, disenrollment, or plan changes effective July 1.

Your company should notify you about the open enrollment period. Contact your Human Resources department if you are unsure or need further information about your company’s healthcare plans and policies.

If you buy your own health insurance and have an ACA-compliant plan, you are also subject to open enrollment, as coverage is only available for purchase during that time (or during a special enrollment period if you have a qualifying event later in the year).

Open enrollment does not apply to things like a short-term health insurance policy or a limited benefit plan.

As of 2024, Washington, DC, and 18 states run their own exchange platforms (this is expected to grow to 19 states by 2025, with Georgia planning to switch to a state-run platform in the fall of 2024).

States that run their own exchange platforms have the option to set their own open enrollment deadlines, and several have opted to extend open enrollment to the end of January or even later.

Prior to the 2022 plan year, state-run exchanges could have open enrollment periods that were longer than the window established by the federal government, but not shorter. But when the federal government issued regulations in the summer of 2021 to extend open enrollment through January 15 (it had previously ended December 15), they noted that state-run exchanges would be allowed to have a shorter window as long as their deadline wasn't earlier than December 15.

Idaho's state-run exchange has opted for a December 15 deadline, although the other 18 state-run exchanges all chose to either align with the federal government's deadline (January 15) or use a later deadline.

For 2025 and future years, the federal government has proposed a rule change that would require all state-run exchanges to begin open enrollment on November 1 and continue it through at least January 15.

Before 2014, there was no such thing as open enrollment for individual health insurance, but insurers in most states could reject applications from people with pre-existing conditions, or charge them higher premiums. Coverage is now guaranteed, regardless of medical history, but enrollment is limited to open enrollment or special enrollment periods.

With employer-sponsored coverage, eligible employees were never rejected or charged higher premiums based on their medical history, but enrollment has always been limited to their initial enrollment window, the annual open enrollment window, or special enrollment periods triggered by qualifying events.

(Employer-sponsored plans could, however, impose waiting periods before pre-existing conditions were covered, if the person didn't have previous coverage. That ended in 2014, under the Affordable Care Act.)

If you're on top of life's little details, you may be well aware of open enrollment. You may even re-assess your plan during that time each year. However, it is more than possible for an individual to forget about or miss their open enrollment period. If you miss out, you have limited options.

Missing Job-Based Open Enrollment

If you miss your company's open enrollment period for health insurance benefits, you may be out of luck. If you have not already signed up for health insurance, there's a good chance you will have to wait until the next annual enrollment window.

But if you were already enrolled last year, your plan likely automatically renewed for this year if you didn't make any changes during your employer's open enrollment period.

Some organizations are more lenient than others about open enrollment (for example, offering a longer enrollment period), but very few will make special exceptions for someone who just forgot, as exceptions are generally prohibited by the terms of the health insurance agreement.

Flexible Spending Account

If your employer offers a flexible spending account (FSA), you have to decide during open enrollment whether to participate and how much to contribute.

The FSA elections are normally irrevocable during the plan year unless you have a qualifying event. But as a result of the COVID pandemic, these rules were relaxed for 2020 through 2022. Employers were allowed (but not required) to permit employees to make changes to their FSA contributions any time during the plan year in those years, without a qualifying event.

In 2023, the rules returned to FSA elections being irrevocable for the whole plan year unless you experience a qualifying life event.

Special Enrollment Period

A special enrollment period is triggered when someone experiences a significant, life-changing event.

This period could be triggered if you are covered under someone else's plan and lose that coverage. For example, if you are covered under your spouse's plan and your spouse loses their job or you get divorced, this would trigger a special enrollment period allowing you to enroll in your company's health plan right away.

Involuntary loss of employer-sponsored coverage is a qualifying event that will allow you to sign up for another employer's health plan (through your spouse's plan or a parent's plan, if available). Depending on the size of the employer and where you live, you might also have the option to continue your employer-sponsored health plans with COBRA or state continuation.

Additionally, if you marry, have a child, or adopt a child, you can enroll your dependents right away during a special enrollment period.

These special enrollment periods also apply in the individual market, although the specific details differ in terms of what counts as a qualifying event and how long the special enrollment period lasts. If you lose your job-based health insurance in the middle of the year, you're eligible to enroll in a plan through the exchange or directly through a health insurance company, even though open enrollment for the year has already ended.

Exceptions

There are a few exceptions to the special enrollment period requirements:

• Native Americans can enroll in a health plan through the exchange at any time, without needing a qualifying event.
• Through at least 2025, there's an ongoing special enrollment period for people with a household income that doesn't exceed 150% of the federal poverty level. The federal government has proposed making this permanent, instead of sunsetting it if and when the American Rescue Plan's subsidy enhancements end.
• For New York or Minnesota residents with an income that doesn't exceed 200% of the poverty level, Basic Health Program coverage is available year-round. New York is working to extend the eligibility limit to 250% of the poverty level.
• Oregon plans to have a Basic Health Program by mid-2024, which would have the same year-round enrollment opportunity as New York and Minnesota.
• Massachusetts residents with income up to 500% of the poverty level who are newly eligible for the state's ConnectorCare program or applying for the first time (in other words, there are some limits on the year-round enrollment access).
• Connecticut residents who are eligible for the Covered Connecticut Program.
  

Enroll in Medicaid or CHIP

Medicaid and Children's Health Insurance Program (CHIP) enrollment are available year-round.

You might find that the income limits for eligibility, especially for CHIP, are higher than you had expected (check out the chart showing income limits for eligibility in each state as a percentage of the poverty level).

So if you're uninsured and have missed open enrollment, check to see if you or your kids are eligible to sign up. Eligibility is based on income, and it varies considerably from one state to another.

Consider Other Plans

Plans that aren't minimum essential coverage, including short-term coverage, fixed indemnity plans, critical illness plans, health care sharing ministry plans, accident supplements, and more are not regulated by the Affordable Care Act and allow year-round enrollment.

If you rely on this type of plan as your only coverage, you're not in compliance with the ACA's individual mandate (requirement that people maintain health insurance). But the federal penalty for non-compliance has been set at $0 since 2019, so you won't be penalized for non-compliance unless you live in a state that has imposed its own coverage requirement and penalty.

Note that when the individual mandate was federally enforced, there was an exemption for people enrolled in health care sharing ministry plans; the plans are not considered health insurance, but members were not subject to a penalty.

There is currently a penalty for being without minimum essential coverage in New Jersey, DC, Massachusetts, California, and Rhode Island. Short-term health insurance is not available in any of those states, but other types of non-ACA-compliant coverage may be available. Having some coverage is generally better than having no coverage at all, even if you'll still be subject to a penalty.

Of the plans that aren't minimum essential coverage, short-term plans tend to be the closest thing to "real" insurance. However, short-term plans don't have to include the ACA's essential health benefits, and can still reject applicants with pre-existing conditions (and generally don't cover any pre-existing conditions, even if the application is accepted). They can also impose caps on the benefits the insurance plan will pay.

So although a short-term plan might work in a pinch to get you through until the next open enrollment period, carefully read the fine print before you apply for a plan.

Summary

Open enrollment is an annual window when you can enroll in health coverage, switch to a different plan, or drop your coverage (that last point is only applicable if you have an employer-sponsored plan; self-purchased individual/family plans can be dropped at any time).

If you miss open enrollment, you may find that you cannot enroll or make changes to your coverage until the following year. However, qualifying life events can trigger a special enrollment period that will allow for mid-year enrollments and plan changes. And some people, including Native Americans and those who are eligible for Medicaid or CHIP, can enroll in coverage anytime.

There are also various health plans (most of which are not sufficient to serve as stand-alone coverage) that can be purchased year-round, although these plans tend to provide fairly limited benefits and generally do not provide coverage for pre-existing conditions.