How Does a Special Enrollment Period Work?
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A special enrollment period (SEP) is a window of time when you can sign up for health insurance outside of open enrollment. You can only qualify for an SEP if you experience a major life event that substantially changes your health coverage needs such as getting married or moving to a new home.
Keep reading for a breakdown of the various ways you can become eligible for special enrollment and what steps you need to take to obtain coverage during an SEP.
What Is a Special Enrollment Period?
A special enrollment period (SEP) is a limited time frame surrounding a major event in your life such as having a child or losing your job, during which you can buy a new health insurance plan or change your existing coverage through the federal Health Insurance Marketplace or your state’s corresponding marketplace.
Unless you qualify for an SEP, you can only sign up for most kinds of Affordable Care Act (ACA) health plans during open enrollment. In most states, open enrollment lasts from November 1 to January 15. Specifically, you can sign up between November 1 and December 15 for coverage beginning at the start of the year or between December 16 and January 15 for coverage starting on February 1.
Keep in mind that you may be able to buy a health plan from a private health insurance company outside of open enrollment without qualifying for an SEP. However, these plans usually aren’t ACA compliant and, because they aren’t listed on the Marketplace, you won’t be able to qualify for any tax credits or other income-based savings whenever you purchase one of these plans.
How Does Special Enrollment Work?
In the process of applying for special enrollment, you may need to submit documents confirming that you have actually experienced a qualifying life event that makes you eligible for an SEP such as a wedding certificate if you recently married or a birth certificate if you just had a child. If you are eligible, then you should be able to compare health insurance rates for various plans based on your income through the Marketplace before settling on and enrolling in a plan.
What Are Common Qualifications for Special Enrollment?
See below for an overview of the major categories of qualifying life events that can enable you to participate in a special enrollment period.
Loss of Coverage
If you or someone else in your household loses their existing health insurance, it will trigger an SEP allowing them to enroll in a new health plan. Some of the situations in this category that can make you eligible for special enrollment include the following:
- You get fired from or quit your job and lose your employer-sponsored group health insurance or you are the dependent of someone who loses their employer-sponsored group health insurance
- The Marketplace plan you are currently enrolled in is discontinued
- Your current plan’s coverage period ends outside of open enrollment and you opt not to renew it
- You are no longer eligible for Medicaid or Children’s Health Insurance Program (CHIP) coverage or you declined to sign up for a private plan during open enrollment because you were told you might be eligible for Medicaid or CHIP but actually aren’t
- You lose Medicare Part A coverage that you did not have to pay a premium for
- You age out of your parents’ health plan upon turning 26 or otherwise cease to be their dependent
- You are no longer eligible to receive coverage through a family member due to death or divorce
You should note that, if you are still someone else’s dependent but choose to unenroll from their health insurance plan, you will not qualify for an SEP unless you become eligible for Marketplace savings due to a drop in household income or a change to your previous coverage.
New Benefit Offers
An employer offering to help you or someone in your household pay for medical services will also trigger a special enrollment period. This may take the form of your employer enrolling you in a group health plan shortly after you start the job or reimbursing you for covered healthcare services through an Individual Coverage Health Reimbursement Arrangement (ICHRA) or Qualified Small Employer Health Reimbursement Arrangement (QSEHRA).
Changes in Your Household
Anytime there is a change in the membership of your household, it will affect your family’s health coverage needs and make you eligible for special enrollment. For example, you could change your health insurance plan at any point in the year following life events such as these:
- You get married or your dependent gets married and moves out of the house
- Someone in your household gives birth, adopts a child or takes in a foster child
- You get divorced or legally separated
- Someone in your household dies
Changes to Your Residence
Since health plan service areas are often limited to specific geographic regions, you will typically qualify for an SEP whenever you move to a new ZIP code or county. This type of SEP can also apply to students who move for school, seasonal workers who move for employment and anyone who moves from a shelter or some other type of transitional housing. However, you won’t qualify for special enrollment if you move somewhere for an extended vacation or for the purpose of receiving medical treatments.
However, you don’t need to show proof of prior coverage to qualify for a moving-based SEP if you are moving from a foreign country to the United States or from an American territory to an American state.
Other Qualifying Life Events
There are several other qualifying life events that can potentially allow you to make changes to your health insurance coverage including the following:
- You gain membership in an indigenous tribe that is recognized by the federal government
- You become an Alaska Native Claims Settlement Act (ANCSA) Corporation shareholder
- You become a United States citizen
- You are released from prison
- Your service as an AmeriCorps State and National, Volunteers in Service to America (VISTA) or National Civilian Community Corps (NCCC) member begins or ends
- An unexpected hospitalization or natural disaster prevented you from signing up for coverage during open enrollment
- You failed to correctly sign up for coverage during open enrollment because of a technical error on the Marketplace website or an insurance agent’s mistake or intentional misrepresentation
- The Marketplace website presented inaccurate information about a plan you signed up for
- You become eligible for savings on a Marketplace plan
- You gain a dependent or become someone else’s dependent due to a court order
- Your spouse has abandoned you or been abusive and you want to remove yourself from their health plan
In addition, some states that operate their own health exchanges may offer an even wider list of qualifying life events that will make you eligible for special enrollment. For example, residents of California may qualify for SEPs on account of situations like these:
- Your expected income is less than 150% of the federal poverty level
- The state or federal government declares a state of emergency due to a crisis like the COVID-19 pandemic or a wildfire outbreak
- You pay the Individual Shared Responsibility Penalty for not having health insurance during the previous tax year
- You qualify for a health insurance stipend through your gig as an independent contractor for a ridesharing or delivery company
- You lose coverage after leaving active military duty, the reserves or the California National Guard
- You qualified for an SEP previously but were not informed of your eligibility in a timely manner
- You have met your share of the costs for your Medi-Cal plan in one of the last two months (this type of SEP can only be triggered once per year)
How Long Does the Special Enrollment Period Last?
Special enrollment periods usually last from 60 days before the qualifying life event to the day the event takes place or from the day the event takes place to 60 days after depending on the type of SEP you are eligible for. Meanwhile, job-based plans are only required to offer an SEP lasting at least 30 days.
What Should You Do if You’re Turned Down for Special Enrollment?
If you believe you should qualify for a special enrollment period but your initial application is rejected, you can file an appeal through the Marketplace. You generally need to file your appeal within 90 days of receiving your Eligibility Notice, although you may be able to get an extension if you have a legitimate reason for missing the deadline. If your appeal is successful, your coverage will retroactively apply to start the day your SEP application was initially denied.
How To Enroll After You Qualify for a Special Enrollment Period
There are various ways to apply for a health plan once you have determined you are eligible to enroll, with the quickest option being to apply online at HealthCare.gov or your state’s equivalent website. You can also enroll over the phone or send a paper application in the mail.
Alternatively, you can work with an agent to get help comparing quotes or take advantage of SmartFinancial’s online marketplace. If you fill out a simple questionnaire, we can get you in touch with local agents who can provide you with health insurance quotes for policies that meet your needs and budget.