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- Annual Special Open Enrollment Window
Having Trouble Meeting Carrier Guidelines?
Each year, the Affordable Care Act (ACA) requires health insurers to offer a one-month Special Open Enrollment Window, when eligible small groups can enroll in coverage without having to meet standard employer-contribution and/or employee-participation ratios.
This Special Open Enrollment Period occurs November 15th through December 15th of each year, allowing eligible small group employers to enroll for coverage effective January 1st of the following year.
The ACA stipulates, “each health insurer that offers health insurance coverage in the individual or group market in the state must accept every employer and individual in the state that applies for such coverage.”
It also says this guaranteed issuance of coverage can only be offered during (special) open enrollment periods, and that plans can only be offered to applicants that live in, work in, or reside in the plans’ service area(s).
Participation and Contribution Requirements
In many states (including California and Nevada), carriers can decline to issue group health coverage if fewer than 70% of employees elect to enroll in coverage. Some carriers may have even tighter participation requirements.
Generally speaking, employees with other coverage (Medicare, other group coverage, individual coverage through the Exchange, etc.) are removed from the participation requirement calculation – though it varies by insurance carrier.
Employer contribution rules require employers to contribute a certain percentage of premium costs for all employees in order to attain group health coverage. Some businesses struggle to meet these contribution requirements for a variety of financial reasons.
Special Open Enrollment Period
Many employers want to offer coverage to employees, but they struggle to meet participation and/or contribution requirements. Employers cannot force employees to enroll in coverage unless the employer pays for 100% of the employees’ premiums, which many employers cannot afford.
The U.S. Department of Health & Human Services (HHS) provides final guidance on this in regulation 147.104(b)(1):
“In the case of health insurance coverage offered in the small group market, a health insurance issuer may limit the availability of coverage to an annual enrollment period that begins November 15 and extends through December 15 of each year in the case of a plan sponsor that is unable to comply with a material plan provision relating to employer contribution or group participation rules.”
If your client groups that are not subject to the ACA’s Applicable Large Employer mandate are struggling with participation and/or contribution, the Special Open Enrollment Window is the time to enroll them in coverage.