Qualifying Life Events for Special Circumstances

EXCEPTIONAL CIRCUMSTANCES

These must be approved by the Washington Health Benefit Exchange. Customers must demonstrate that the exceptional circumstances prevented them from enrolling during open enrollment and that the exceptional circumstances occurred within 60 calendar days of the request for a special enrollment period. The Exchange follows guidance from the US Department of Health and Human Services (HHS) to determine what exceptional circumstances are.  In general, exceptional circumstances are unanticipated and unexpected events that are beyond the control of the customer that prevent enrollment during the regular open enrollment period.

The Washington Health Benefit Exchange will determine the day your coverage begins based on the event you have reported.

Some examples of exceptional circumstances include, but are not limited to:

  • Domestic Violence or Spousal Abandonment.
  • Unexpected hospitalization or temporary cognitive disability.
  • Natural disasters (earthquake, massive flooding, hurricane, or widespread power outage).
  • Acts of foreign or domestic terrorists that kept the customer from meeting normal deadlines.
  • A planned or unplanned system outage of Healthplanfinder that kept the customer for enrolling during open enrollment.
  • Customer was sold fraudulent coverage but didn’t become aware that it was fraudulent until after open enrollment.

SYSTEM ERRORS THAT KEPT THE CUSTOMER FROM ENROLLING

  • The system issues must be documented with a ticket;
  • The issue must have occurred during open enrollment or a special enrollment period; and
  • The special enrollment period must be requested within 60 days of the date of the system error.

Coverage will begin the month it would have begun if the customer had not received system errors.

ERRORS OF THE WASHINGTON HEALTH BENEFIT EXCHANGE

This is not related to Washington Healthplanfinder functionality. Enrollment or non-enrollment in a Qualified Health Plan or Qualified Dental Plan is unintentional, inadvertent or erroneous and is the result of the error, misrepresentation or inaction of an officer or employee of the Exchange.

Coverage will begin based on the circumstances of the special enrollment period.

UNRESOLVED CASEWORK

A customer’s issue didn’t get resolved before the end of open enrollment.

Coverage will begin the month it would have begun if the customer didn’t experience any issues.

CONTRACT VIOLATION BY A QUALIFIED HEALTH PLAN

The customer or their dependents are enrolled in a Qualified Health Plan that violates a provision of its contract.

Coverage will begin based on the circumstances of the special enrollment period.

ERRORS OR OMISSIONS BY AN ENROLLMENT ASSISTOR (NAVIGATOR, BROKER, ETC.)

Misconduct resulted in the customer:

  • Not getting enrolled in a plan
  • Being enrolled in a plan that was not the one they asked to be enrolled in
  • Not getting tax credits or cost-sharing reductions that they were eligible for

Coverage will begin based on the circumstances of the special enrollment period.