Special Enrollment Period Reference Guide

The Marketplace open enrollment is the time each year when people can newly enroll in a plan or change to a diferent plan through the exchange.  But, certain events can occur each year that can trgieer a special enrollment period (SEP), when a person my be able to change their Marketplace plan or newly enroll in a Marketplace plan outside of the open enrollment period.

These SEPs are specific to Marketplace insurance only.  There are SEPs that cover Medicare, and while the names may be the same, the information given here should not be used to guide a decision with Medicare. 

Also, these SEPs are specific to states who that have a Federally-Facillitated Marketplace (FFM) or use the Healthcare.gov platform.  State-based Marketplaces may have additional SEP opportunities not listed here as states can establish their own rules as long as they are more protective of consumers.

When you make a plan change due to an SEP, the information you submit is considered true, but still needs to be verified.  You have 30 days to submit the needed documents, and failure to do so may result in coverage not starting.  All documents can be uploaded to your Healtcare.gov account for verification.

Getting Started

While an SEP can open up any time of the year, there are time requirements to making changes to any health coverage.  Generally, you will have 60 days from the time a qualifying event occurred to make a plan change.  After changes have been made, you will have, usually, 30 days to provide documentation proving that you did qualify for the SEP in the first place.  Also, and probably most importantly, you almost always need to have insurance to begin with.  There are not many SEPs that allow you to get insurance for the first time.

There are exceptions to this.  Some SEPs allow you to make changes before the qualifying event, such as moving, where you can change a plan prior to a move so that you do not lose coverage.  Others do not require you ro provide proof.  Some allow yo to purchase a Marketplace plan even if yo do not have insurance currently.  Every SEP is different in what it trigger and how it allows you to change coverage.

Qualifying Events

A qualifying event is any one of a number of listed things that can open up an SEP.  Examples include the birth of a child, a death in the family, moving across town, or loss of income due cutting hours at work.  All of these would allow for an SEP and the opportunity to change you coverage.

There are a lot of different qualifying events.  Not all of them will be listed, but below are the most common ones.  Additionally, HealthCare.gov has a tool that can help you determine if you qualify for  an SEP.  That tool can be found here.

This normally comes up if you or anyone in your household loses their qualifying health coverage.  Examples include changes to Medicaid coverage, losing coverage through a job, or discontinued individual or group plans.

Importantly, coverage cannot be dropped voluntarily and the coverage you had needs to be considered Minimum Essential Coverage (this is type of plan that meets ACA requirements.  You can read more about that here.

When one of these events happen, you normally have 60 days to make a change to your coverage.

Adopting, giving birth, getting married, and accepting foster kids are all examples of when this SEP would trigger.

Off the exchange, there are also SEPs that trigger if you lose a dependent through divorce or legal separation, or through death. However, because they are not through the exchange, you would not receive any subsidy and would need to go directly to the health insurance company.

Anytime you move, even if it just across town, IF you either gain access to new plans or you lose access to your current plan, you can change. This sounds like it wouldn’t happen often, but plans change based on ZIP code, so even a minor change can open up this SEP.

Other reasons for this SEP include moving from a shelter or transitional housing, moving due to seasonal employment, moving for school, or moving from outside the US into the US.

This is one of the few SEPs that allows you make changes BEFORE you move.

This is a fancy way of saying that your financial situation changes and you can adjust your health coverage. This can happen because your income increases and you no longer receive an APTC, or your income could decrease and you are now eligible for CRS.

Those that experience changes to their resident status, those that have been recently released from incarceration, as well as certain members of federally recognized tribes and Alaskan Natives all use this SEP.

All of these are very situation dependent and vary person to person. Some examples include not receiving notice that a previous SEP was open, natural disasters that prevented you from enrolling in coverage, your identity being compromised (DMI), or the Marketplace taking too long to review documents you had previously sent in for review.

Most of these SEPs require either a call to the Marketplace Call Center or a conversation with a CMS Caseworker.

What to do Once You Have An SEP

More often than not, you will only be able to change your coverage within the same metal tier that you are currently in (learn more about Metal Tiers here).  You will have about 60 days to pick your plan.  When your plan becomes active is determined by the Coverage Effective Date of the SEP.  Additionally, you will need to make sure you have met all Prior Coverage Requirements before selecting any plan change.

Give us a call if you think you may qualify for an SEP and we can help guide you through the process.

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