Special Enrollment Periods (SEPs) are times outside the regular Open Enrollment Period (OEP) when you can sign up for health insurance. SEPs are triggered by specific life events that involve a change in your situation — like changing where you live, losing other health coverage, or having a change in your family composition. Here is a list of common causes for the creation of Special Enrollment Periods in health insurance plans:
Most common causes
The following list covers the most common causes for SEPs in health insurance plans, particularly under the Affordable Care Act (ACA) in the United States.
- Loss of Health Coverage: Losing eligibility for Medicare, Medicaid, or CHIP. Loss of employer-based coverage, whether through termination (including voluntary quitting) or a reduction in hours that results in loss of eligibility for coverage.
- Changes in Household Size:
- Marriage or divorce.
- Birth or adoption of a child.
- Death in the family that results in a change in eligibility.
- Change in Residence: Moving to a different ZIP code or county, moving to the U.S. from a foreign country or United States territory, if you’re a student moving to or from the place you attend school, or a seasonal worker moving to or from the place you both live and work.
- Changes in Eligibility for Financial Assistance: Changes in income that affect eligibility for premium tax credits or cost-sharing reductions.
- Gaining Membership in a Federally Recognized Tribe or Status as an Alaska Native Claims Settlement Act (ANCSA) Corporation Shareholder: Members of federally recognized tribes and ANCSA shareholders can sign up for or change plans once a month throughout the year.
- Leaving Incarceration: Release from jail or prison.
- Gaining or Maintaining Status as a Refugee, Asylee, or Other Immigration Status: Gaining lawful presence or certain immigration statuses in the U.S.
- AmeriCorps Members: Starting or ending service in AmeriCorps State and National, VISTA, or NCCC programs.
Other causes
There are additional circumstances that could qualify someone for an SEP, reflecting the ACA’s flexibility in accommodating life changes and unforeseen circumstances, further expanding the scope of what might allow for enrollment outside of the usual Open Enrollment Period. Here are a few more examples:
- Misinformation, Misrepresentation, or Inaction: If you missed enrollment due to misinformation or misrepresentation by an enrollment counselor, agent, broker, or a mistake in the application process from the Marketplace.
- Technical Errors Related to Enrollment: Issues with the website or Data Matching errors that prevented or complicated enrollment.
- Exceptional Circumstances: Natural disasters (such as hurricanes or earthquakes) that prevented you from enrolling. Other exceptional circumstances might include serious medical conditions or hospitalizations that prevented you from enrolling.
- Violence, Abuse, or Spousal Abandonment: Situations involving domestic violence, abuse, or spousal abandonment that affect the ability to enroll.
- Plan or Benefit Violation: If your plan significantly violated its contract with you.
- Eligibility Appeals: Winning an appeal that grants you a special enrollment period.
- Gaining or Continuing Coverage through a Job: If you start or end employment that offers health insurance, this can also trigger an SEP.
- COBRA Coverage: Exhausting your COBRA coverage can qualify you for an SEP, as can making a decision related to COBRA elections after losing job-based health coverage.
- Gaining Citizenship or Lawful Presence: Becoming a U.S. citizen, U.S. national, or gaining lawful presence in the U.S.
Please note that the above lists are not comprehensive. These life events may qualify you for a Special Enrollment Period, allowing you to enroll in a new health plan or change your current plan outside the annual Open Enrollment Period. It’s important to check with the specific health insurance marketplace or regulatory body in your area, as some details and qualifying events may vary by state or be subject to specific rules and interpretations. It’s important to note that you typically have 60 days from the date of the qualifying life event to enroll in a new health plan or change your current plan.
Was this helpful?
0 / 0