Sec. 14.35.07.17. Special Enrollment Period — Exceptional Circumstances Through the Individual Exchange

A. Prior to January 1, 2020, an individual, an enrollee or an enrollee’s dependent is eligible for a special enrollment period set forth in 45 CFR §155.420(c)(3) if the triggering event set forth in 45 CFR §155.420(d)(9) occurs.

B. Effective January 1, 2020, a qualified individual, enrollee, qualified individual’s dependent, or enrollee’s dependent is eligible for a special enrollment period if:

(1) The Individual Exchange determines that, at the time of the qualified individual’s, enrollee’s, qualified individual’s dependent’s, or enrollee’s dependent’s application for coverage, the individual experienced exceptional circumstances that prevented the qualified individual, enrollee, qualified individual’s dependent or the enrollee’s dependent from enrolling during open enrollment or a special enrollment period, if the individual was determined eligible for the special enrollment period by the Individual Exchange; and

(2) The qualified individual, the enrollee, the qualified individual’s dependent, or the enrollee’s dependent notifies the Exchange within 30 calendar days of the exceptional circumstances.

C. The Exchange, at its discretion, may waive the 30-calendar-day reporting requirement under §B(2) of this regulation if the exceptional circumstance prevented the qualified individual from providing notice.

D. Exceptional circumstances may include, but are not limited to:

(1) A serious medical condition, such as an unexpected hospitalization or temporary cognitive disability;

(2) Domestic abuse or violence;

(3) Spousal abandonment;

(4) A natural disaster, such as an earthquake, a massive flooding, or a hurricane;

(5) A significant life event resulting in lack of access to the qualified individual’s or enrollee’s Individual Exchange application or account and the qualified individual, the enrollee, the qualified individual’s dependent, or the enrollee’s dependent has experienced a change in situation or status that now requires that the qualified individual, the enrollee, the qualified individual’s dependent, or the enrollee’s dependent obtain minimum essential coverage; or

(6) Policy action that would result in a premium change of prospective coverage that would adversely impact the qualified individual and the qualified individual did not receive reasonable notice to act upon the material change.

E. Notification to the Individual Exchange under §B(2) of this regulation shall be satisfied if the qualified individual, the enrollee, the qualified individual’s dependent, or the enrollee’s dependent provides notice:

(1) To an Individual Exchange-certified navigator, an Individual Exchange-authorized broker, or an Individual Exchange-certified consolidated service center representative; and

(2) Using any of the methods of communication listed under Regulation .03B of this chapter.

F. The effective date of coverage for a qualified individual, an enrollee, a qualified individual’s dependent, or an enrollee’s dependent who is determined eligible for a special enrollment period under this regulation and selects a QHP during the special enrollment period under §B of this regulation:

(1) Shall be a date determined by the Individual Exchange as appropriate based on the circumstances of the qualified individual’s, the enrollee’s, the qualified individual’s dependent’s, or the enrollee’s dependent’s exceptional circumstances;

(2) Shall be no earlier than the date the qualified individual’s, the enrollee’s, the qualified individual’s dependent’s, or the enrollee’s dependent’s coverage would have begun or continued, but for the exceptional circumstances; and

(3) May be retroactive or prospective dependent on the nature of the exceptional circumstance.