Special Enrollment
Special Enrollment Period (SEP) is a time outside the yearly Open Enrollment Period when you can sign up for health insurance.
♦ September 2021, CMS finalized a new Special Enrollment Period (SEP) that grants year-round enrollment if an applicant's household income does not exceed 150% of the federal poverty level (FPL).
This applies as long as you are not eligible in your state for Medicaid or CHIP.
Life events
You qualify for a Special Enrollment Period (SEP) if you’ve had certain life events, including losing health coverage, moving, getting married, having a baby, or adopting a child.
→ Pregnancy is not considered a qualifying life event. However, loss of pregnancy related coverage provided through CHIP may be.
♦ Maryland legislature added pregnancy as a Life Event that would trigger an SEP. This took effect for plans after January 1, 2020.
► COVID-19 pandemic is an exceptional circumstance that did trigger an SEP in many states. Currently with the pandemic subsiding there is no Covid specific SEP.
During 2020, the Trump administration refused to allow a special ACA enrollment for people who lost coverage due to the pandemic. States running their own exchanges could offer an SEP, which most did.
♦ California, Colorado, Maryland, Massachusetts, Minnesota, Nevada, New York, Rhode Island, Vermont, Washington and the District of Colombia all opened their doors to allow the uninsured and recently laid-off workers the opportunity to obtain health coverage.
• The Department of Labor and the IRS issued a joint rule extending open enrollment for group health plans during the pandemic. Companies were encouraged but not required to offer an extend SEP.
Time limit
If you qualify for an SEP, you usually have up to 60 days following the event to enroll in a plan. If you miss that window, you have to wait until the next Open Enrollment Period to apply.
Important: If you don't enroll in a plan during the 60-day window following your SEP event, you cannot enroll until the next open enrollment period.
You can enroll in Medicaid and the Children’s Health Insurance Plan (CHIP) any time of the year, whether you qualify for a Special Enrollment Period or not.
Job-based plans must provide a Special Enrollment Period of at least 30 days.
You can enroll in an insurance plan through the Health Insurance Marketplace only if you have a life event that qualifies you for a Special Enrollment Period.
♦ HealthCare.gov has a small PDF file that provides some general information. It is called Understanding Special Enrollment Periods.
May need proof
In 2016, the federal Marketplace began requiring people to provide documentation of eligibility for special enrollment for some of the most common qualifying events:
Loss of minimum essential coverage
Permanent move
Birth, adoption, placement for adoption, placement for foster care
Child support or other court order
Marriage
2017 Rule Changes
New limitations for people currently enrolled in plans through the Marketplace were finalized.
♦ Now if you qualify for a SEP you can only change plans within the same metal level as the plan you currently have.
There will be a few exceptions allowed.
• Income changes, you are now eligibility for cost-sharing reductions (CSR). This situation will permit someone not currently enrolled in a silver plan to enroll in one to take advantage of CSR.
• Gaining a dependent through marriage, birth, adoption or foster care placement will trigger a SEP. The new dependent or spouse may be added to your current plan or you can enroll the dependent in a separate plan.
2019 changes
• There will be an additional SEP for loss of pregnancy related coverage provided through the Children’s Health Insurance Program (CHIP).
• The prior coverage requirement will have an additional exemption, for people who lived in an area where no plans were offered through the Marketplace. You must have lived at least 1 day during the 60 days before a qualifying event for an SEP to apply.
Loss of Health Coverage
You may qualify for a Special Enrollment Period if you or anyone in your household lost qualifying health coverage in the past 60 days OR expects to lose coverage in the next 60 days.
Coverage losses that may qualify you for a special enrollment period:
Losing job-based coverage
Losing COBRA coverage
Losing individual health coverage for a plan or policy you bought yourself
Losing eligibility for Medicaid or CHIP
Losing eligibility for Medicare
Losing coverage through a family member
COBRA
♦ If you are eligible for COBRA, you should consider all options you may have to get other health coverage before you decide.
There may be more affordable or better coverage for you and your family through other group health plans (such as a spouse's plan), the Health Insurance Marketplace, or Medicaid.
It is important to understand that you may qualify for a Special Enrollment Period if you lose your health coverage through your employer, if your employer stops offering coverage. If you quit or were fired you may also qualify. Your hours may have been reduced and that causes you to loose coverage.
The reason for losing coverage cannot be that you chose not to buy insurance or you failed to pay the insurance premium.
You may qualify, if your employer no longer offers a plan that is considered qualified coverage.
If your employer offers a plan that is considered affordable and meets minimum value standards, you can buy insurance through the Marketplace but you will not be able to receive a Premium Tax Credit, also called a subsidy.
If you are receiving insurance coverage through COBRA you may qualify for a Special Enrollment Period if your COBRA coverage has run out.
You may qualify if your former employer was contributing to your COBRA coverage and they decided to stop contributing, resulting in you having to pay the full costs.
If your coverage through COBRA will end soon, you should start the enrollment process so you will not experience a lapse in insurance coverage.
♦ You do not qualify if you are already paying the full cost of COBRA and then you decide to stop or you fail to pay the premiums and the insurance company cancels you. You would need to let COBRA run out.
♦ If you reach the Open Enrollment period you can voluntarily drop COBRA and enroll in a Marketplace plan at that time. Review the timing very carefully at the Marketplace because you do not want to risk having a gap without any insurance coverage.
You may qualify if you lose individual coverage because your plan decided to discontinue. You may qualify if your student health plan ends when you leave school. If you move out of your plan’s service area you may lose eligibility also.
You cannot voluntarily drop coverage or fail to pay your premiums.
You may qualify if you are a dependent and you lose health coverage because your parent or other family member under which you receive coverage loses their coverage because of a job loss or divorce.
You may qualify if the reason is because your status changes and you are no longer a dependent.
There are many not so clear scenarios that may qualify.
You should try applying through the Marketplace to be sure.
Changes in household size
You may qualify for a Special Enrollment Period if you or anyone in your household in the past 60 days:
• Got married. Pick a plan by the last day of the month and your coverage can start the first day of the next month.
• Had a baby, adopted a child, or placed a child for foster care. Your coverage can start the day of the event — even if you enroll in the plan up to 60 days afterward.
• Got divorced or legally separated and lost health insurance. Note: Divorce or legal separation without losing coverage doesn’t qualify you for a Special Enrollment Period.
• Death. You’ll be eligible for a Special Enrollment Period if someone on your Marketplace plan dies and as a result you’re no longer eligible for your current health plan.
Changes in residence
Household moves that qualify you for a Special Enrollment Period:
• Moving to a new home in a new ZIP code or county
• Moving to the U.S. from a foreign country or United States territory
• A student moving to or from the place they attend school
• A seasonal worker moving to or from the place they both live and work
• Moving to or from a shelter or other transitional housing
Note: Moving only for medical treatment or staying somewhere for vacation doesn’t qualify you for an SEP.
Starting July 2016
You must prove you had qualifying health coverage for one or more days during the 60 days before your move.
You don’t need to provide proof if you’re moving from a foreign country or United States territory.
More qualifying changes
Other life circumstances that may qualify you for a Special Enrollment Period:
• Changes that make you no longer eligible for Medicaid or the Children’s Health Insurance Program (CHIP).
• Being a member in a federally recognized tribe or having status as an Alaska Native Claims Settlement Act (ANCSA) Corporation shareholder.
• Becoming newly eligible for Marketplace coverage because you’ve become a U.S. citizen, U.S. national, or lawfully present individual.
• Becoming newly eligible for Marketplace coverage because you’ve been released from incarceration (detention, jail or prison).
• AmeriCorps members starting or ending their service.
Other complicated cases
Below are a few events that may also qualify you for a Special Enrollment Period:
Exceptional Circumstance
Marketplace Enrollment or Plan Error
An Increase in Income or Move - Making Eligible Now
Learned Ineligible for Medicaid or CHIP
Gain or Become a Dependent
Experience Domestic Abuse or Spousal Abandonment
An Appeal Was Successful
Learn more about these situations at HealthCare.gov.
♦ The list can change so if you do not see your situation listed do not give up, try visiting the link above.
