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The HealthCare Reform Special Enrollment Period (SEP) allows individuals to enroll in an Affordable Care Act Marketplace plan or change their existing plan outside of the regular open enrollment period due to certain qualifying events.
You may qualify for a Special Enrollment Period if you’ve had certain life events, including losing health coverage, moving, getting married, having a baby, or adopting a child, or if your household income is below a certain amount. Special Enrollment qualifying events include life changes such as marriage, birth or adoption of a child, loss of other health coverage, or relocation to a new area.
Special Enrollment Events include:
Life Changes:
- Changes in Household: Events such as marriage, having a baby, adopting a child, or losing coverage due to divorce, legal separation, or death of someone on the Marketplace plan may trigger an SEP.
- Changes in Residence: Moving to a new ZIP code, county, or from a foreign country or U.S. territory qualifies for an SEP, as does moving to or from certain places like school, seasonal work locations, or transitional housing.
- Loss of Health Coverage: Losing qualifying health coverage within the past 60 days, or expecting to lose coverage in the next 60 days, qualifies for an SEP. This includes various types of coverage loss, such as job-based coverage, individual health coverage, Medicaid or CHIP coverage, eligibility for Medicare, coverage through a family member, or offers of assistance from an employer.
Additional Qualifying Changes:
- Offer of Individual Coverage HRA or QSEHRA: Being offered an individual coverage HRA or a Qualified Small Employer Health Reimbursement Arrangement (QSEHRA) within the past 60 days, or expecting to be offered one in the next 60 days, qualifies for an SEP.
- Other Situations: Membership in a federally recognized tribe, becoming a U.S. citizen, leaving incarceration, or starting/ending service as an AmeriCorps member are also qualifying events for an SEP.
Unexpected Situations:
- Serious Medical Condition or Incapacitation: If you faced a serious medical condition, temporary cognitive disability, or were incapacitated due to an unforeseen circumstance, you may qualify for an SEP. This includes instances like unexpected hospitalizations or temporary disabilities.
- Natural Disasters: Individuals affected by natural disasters such as earthquakes, floods, or hurricanes may be eligible for an SEP. Eligibility is based on living in a county designated for "individual assistance" or "public assistance" by FEMA. Enrollment must be completed within 60 days from the end of the FEMA-designated incident period.
- Enrollment or Plan Information Errors: Misinformation, misconduct, or technical errors during enrollment, or display errors regarding plan information on HealthCare.gov, can qualify individuals for an SEP. This includes situations where technical issues prevented enrollment or if incorrect plan information was displayed.
- New Eligibility for Savings: Those who were previously ineligible for premium tax credits due to low income but experienced an increase in household income or moved to a new location within the last 60 days may qualify for an SEP.
- Found Ineligible for Medicaid or CHIP: Individuals who applied for Marketplace or Medicaid/CHIP coverage during an enrollment period but were later found ineligible may qualify for an SEP, regardless of whether they applied through the Marketplace or a state agency.
- Gaining or Becoming a Dependent: Becoming a dependent or gaining a dependent through a court order, domestic abuse/violence survivorship, or spousal abandonment may trigger an SEP.
- Successful Appeal Decision: Individuals whose appeal with the Marketplace is successful may have the option to enroll in or change plans based on the appeal decision.
Individuals who qualify for an SEP should contact the Marketplace Call Center to complete their enrollment, as online enrollment may not be available for these specific circumstances.
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