Laws and Regulations: Practice Questions & Explanations

ACA marketplace plans have an annual open enrollment period, typically November 1 through January 15 in states using the federal exchange (HealthCare.gov). State-based exchanges may set different periods. During open enrollment, anyone can enroll in or change plans without restriction. Outside open enrollment, enrollment requires a 'qualifying life event' (QLE) that opens a special enrollment period (SEP) — examples: marriage, divorce, birth or adoption of a child, loss of other coverage, moving, change in income affecting subsidy eligibility. SEPs are typically 60 days from the QLE. The structure prevents adverse selection (people waiting until they are sick to enroll). Medicaid and CHIP have year-round enrollment; Medicare has its own annual enrollment periods.

Guaranteed issue means an insurer must offer coverage to an eligible applicant regardless of their health status or medical history, and cannot decline them or charge more based on pre-existing conditions. This consumer protection is a feature of various group plans and, under the Affordable Care Act, of individual major medical coverage sold in the marketplace. Guaranteed issue increases access for people with health conditions, balanced by mechanisms (like enrollment periods) that manage adverse selection. The specific requirements derive from state and federal law and can change. Understanding guaranteed issue as the obligation to cover regardless of health status is standard regulations content.