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Special Enrollment Period Resources


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Special Enrollment Period Resources

Special Enrollment Period Resources


Under the Affordable Care Act (ACA), health insurers selling individual coverage are required to sell a plan to all applicants, with certain limited exceptions. One of the most important exceptions allows insurers to limit the amount of time during the year that policies are available, called an open enrollment period. Under federal rules, for coverage beginning in 2015, the open enrollment period will be November 15, 2014 to February 15, 2015.

Individuals who lose coverage or experience life changes, such as marriage or the birth of a child, may  qualify for a special enrollment period (SEP), which gives them the right to sign up for a plan outside of the open enrollment period.

Federal rules lay the groundwork for special enrollment opportunities: qualifying events, enrollment period length and effective dates for coverage obtained through a special enrollment. However, states have some flexibility to expand on open enrollment and special enrollment opportunities. For example, states can require more frequent or longer open enrollment periods outside the marketplace. However, inside the marketplace, states cannot create qualifying events or extend the period of open enrollment without federal permission.

It is important to note that there is nothing that prevents insurers from selling policies outside of the open enrollment period. If they do, they must still comply with all the rules against discrimination based on health status. However, experts don’t expect insurers to do so, since they would be potentially enrolling people who wait until they’re sick to seek coverage.

Qualifying Events for Special Enrollment Periods (SEP)

These circumstances apply to the qualifying individual and any dependents

  • Loss of minimum essential coverage, including
    • Employer coverage, due to loss of job or loss of eligibility for coverage through, for example, reduction in hours
    • Medicaid or CHIP
    • High-risk pool coverage
    • Student health plan
    • Exhaustion of COBRA. Note: does not apply to loss of minimum essential coverage due to failure to pay premiums on a timely basis or other voluntary loss of coverage (e.g., dropping employer coverage or COBRA)
    • Newly eligible for tax credits because employer coverage is no longer affordable or adequate
  • Gain a dependent (or become a dependent) through marriage, birth, adoption or placement in foster care. Note that divorce is not a trigger unless it’s accompanied by another circumstance, such as loss of minimum essential coverage or a permanent move
  • Access to new QHP through a permanent move (could be within a state or out of state)
  • Change in status to become a citizen or lawfully present
  • Enrollment or nonenrollment due to error or inaction by the marketplace
  • Enrollment or disenrollment is unintentional, inadvertent or erroneous and is the result of an error, misrepresentation or inaction of office, agent or employee of exchange or HHS
  • Exceptional circumstances, including loss of eligibility for a hardship exemption
  • Special rule for American Indians and Alaska Natives: may enroll in or change marketplace plans one time per month

Special enrollment periods that apply only to individuals already enrolled in a marketplace plan (QHP)

  • Enrollee or dependent demonstrates substantial contractual violation by the QHP
  • Enrollee (or enrollee’s dependent enrolled in the same QHP) is determined newly eligible or ineligible for advanced payment of premium tax credits [1]
  • Enrollee has change in eligibility for cost-sharing reductions

Time period to enroll

Individuals generally have 60 days from event that triggers SEP to enroll in plan. However, individuals who will lose minimum essential coverage can begin enrollment into new coverage 60 days prior to the loss of the coverage.

Effective dates for coverage obtained through special enrollment opportunity

  • In general, coverage obtained through SEP will become effective on the first day of the following month. This applies in the case of loss of minimum essential coverage and marriage.
  • In the case of gaining a dependent through birth, adoption or foster care, coverage is effective on the date of the birth/adoption/foster placement.
  • In the case of change in citizenship status, permanent move, or the special rule for American Indians and Alaska Natives, the regular coverage effective dates apply: if the person enrolls between the 1st and 15th of the month, coverage is effective on the first day of the following month; if the person enrolls between the 16th and the end of the month, coverage becomes effective on the first day of the second following month.

[1] Learn more about the the types of situations that are excluded from this because not already enrolled in QHP.