What is the Special Enrollment Period (SEP)?

The Special Enrollment Period (SEP) is a gateway to health insurance for those who do not have health insurance and need to purchase medical coverage outside of the annual enrollment period. 

You can have a special enrollment opportunity to sign up for private, non-group coverage during the year, other than during Open Enrollment period, if you have a qualifying life event. Events that trigger a special enrollment period (SEP) are:

• Loss of eligibility for other coverage (for example if you quit your job or were laid off or if your hours were reduced, or if you lose student health coverage when you graduate) Note that loss of eligibility for other coverage because you didn’t pay premiums does not trigger a special enrollment opportunity
• Marriage or divorce (limitations apply)
• Gaining a dependent (for example, if you give birth to or adopt a child). Note that pregnancy does NOT trigger a special enrollment opportunity in most states
• Loss of coverage due to loss of dependent status (for example, because of divorce, legal separation, death, or “aging off” a parents’ plan when you turn 26)
• A permanent move to another state or within a state if you move outside of your health plan service area (limitations apply)
• Exhaustion of COBRA coverage
• Losing eligibility for Medicaid or the Children’s Health Insurance Program
• Income increases or decreases enough to change your eligibility for Marketplace subsidies
• Change in immigration status
• Enrollment or eligibility error made by the Marketplace or another government agency or somebody, such as an assister, acting on their behalf.

Note that some triggering events will only qualify you for a SEP in the health insurance Marketplace; they do not apply in the outside market. For example, if you gain citizenship or lawfully present status, the Marketplace must provide you with a special enrollment opportunity.

When you experience a qualifying event, your SEP will last 60 days from the date of that triggering event.  

If you can foresee loss of other coverage (for example, you know the date when you will graduate and lose student health coverage) you can ask the Marketplace for a SEP up to 60 days in advance so new coverage will take effect right after your old coverage runs out. However, in HealthCare.gov states, you cannot ask for an advance SEP if you anticipate coverage loss due to a permanent move.

States have flexibility to expand special enrollment opportunities for consumers. Check with your State Marketplace for more information.

Do I have to prove eligibility for a special enrollment period?

Yes, in most states.  The federal Marketplace (HealthCare.gov) requires people to provide documentation of eligibility for special enrollment before you can enroll in coverage.  Pre-enrollment verification is required for the following qualifying events:

• Loss of minimum essential coverage
• Permanent move
• Marriage
• Adoption, placement for adoption, placement for foster care, or child support or other court order, and

If you experience one of these qualifying events and apply for coverage in a federal Marketplace state, HealthCare.gov will let you select a health plan, but will delay the effective date of coverage while it verifies your eligibility for the SEP.

HealthCare.gov will tell you what documents are acceptable to verify your eligibility for the SEP and how to submit them.  Once you apply for the SEP and select a health plan, you will have 30 days to provide documentation to the Marketplace.  Once the Marketplace verifies your eligibility, you will be able to complete enrollment in the plan you selected.

It is very important to act quickly to complete this verification process.  If you do not submit the required documentation within 30 days, your plan selection will be cancelled and you will no longer be eligible for the SEP.

If you submit documentation on time but the Marketplace determines it to be insufficient, you can apply for an extension of the 30-day review period to submit additional documentation. However, you cannot apply for an extension of your special enrollment period.  If your eligibility is not verified by the end of your 60-day SEP, your plan selection will be cancelled and you will not be able to enroll until the next open enrollment period.

How does the "marriage" special enrollment period work?

When you get married, you can qualify for a special enrollment period (SEP).  You and your spouse can sign up for coverage in the Marketplace. The special enrollment period lasts for 60 days from the date of marriage.  If you enroll in coverage through the marriage SEP, coverage will start on the first day of the following month.

f you live in a HealthCare.gov state, restrictions apply.  To be eligible for the marriage SEP, at least one of you must have been enrolled in minimum essential coverage (such as a job-based plan, Marketplace plan, or Medicaid) for at least 1 day during the 60 days preceding the date of marriage.

There are exceptions to this limit on marriage SEP eligibility:

If at least one spouse was living in a foreign country or U.S. territory during the 60-days prior to enrollment, the prior coverage requirement does not apply

If at least one spouse is a member of a federally recognized Native American tribe or an Alaskan Native, the prior coverage requirement does not apply

In addition, for people currently enrolled in the Marketplace through HealthCare.gov, the marriage SEP can only be used either to add the new spouse to the current Marketplace plan or to enroll the new spouse in a separate Marketplace plan.  The currently-enrolled spouse cannot use the marriage SEP to change plans.

This restriction on plan selection does not apply for Native Americans or Alaska Natives, or for victims of domestic abuse or spousal violence.

These restrictions on eligibility for the marriage SEP and on plan selection do not apply in the SHOP Marketplace or for people using an SEP to join an employer-sponsored group health plan.

State-run Marketplaces have flexibility to expand special enrollment opportunities for consumers. Check with your State Marketplace for more information.

How does the "new dependent" special enrollment period work?

When you have a baby – or when you adopt a child, a child is placed with you for adoption or foster care, or if you gain a dependent through a court order – you can qualify for a new dependent special enrollment period.  You and your dependents can enroll in coverage through the Marketplace.

The new dependent SEP lasts for 60 days from the date of the child’s birth (or adoption, court order, etc.).  New coverage generally will take effect retroactive to the date of birth (adoption, court order, etc.)

If you are already enrolled in Marketplace coverage through HealthCare.gov, you can add your new dependent to your Marketplace plan or buy a different, separate policy for the child.  You cannot use the “new dependent” SEP to change health plans for already-covered family members.

This limitation on plan selection does not apply if you are an American Indian or Alaska Native.  In addition, if your current Marketplace plan doesn’t cover dependents, you and your dependents can enroll together in a new plan at the same metal level as your current Marketplace plan.

State-run Marketplaces have flexibility to expand special enrollment opportunities for consumers. Check with your State Marketplace for more information.

How does the "permanent move" special enrollment work?

If you move to or within a HealthCare.gov state, you will be eligible for a special enrollment period only if you had previously been enrolled in other coverage.  You must have been enrolled in minimum essential coverage (such as a job-based plan, Marketplace plan, or Medicaid) for at least 1 day in the 60 days preceding the date of the permanent move in order to qualify for the permanent move special enrollment period.

There are exceptions to this rule:

If you previously lived in a state that did not expand Medicaid eligibility and were ineligible for Marketplace coverage in that state because your income was below the poverty level, and if you move to another state where you become newly eligible for premium tax credits, you will be eligible for the permanent move special enrollment period when you move to the new state

If you moved from outside of the United States or a U.S. territory, you are eligible regardless of prior coverage

If you are newly released from incarceration, you are eligible regardless of prior coverage

The permanent move SEP lasts 60 days from the date of your move.  Coverage will start on the first day of the following month; or, if you select your new plan after the 15th of the month, new coverage will start on the first day of the second following month.  In HealthCare.gov states, you will not be able to apply for the permanent move SEP in advance of your move date.    As a result, people who move to or within HealthCare.gov states may experience a break in coverage while they wait for their new plan to take effect.

When you apply for the permanent move SEP in a HealthCare.gov state, you will be required to provide documentation of your prior address, your new address, and evidence of loss of prior coverage.

State-run Marketplaces have flexibility to expand special enrollment opportunities for consumers. Check with your State Marketplace for more information.

Source: KFF