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5 ways to qualify for a Special Enrollment Period


As you likely know, the health insurance marketplace is a hub for individuals and families that are looking to purchase health insurance. Looking at the marketplace, you can find a wide range of plans that can fit both your health needs and your budget.

That being said, one thing that new purchasers may not recognize is that there are restrictions on when you can purchase a health care plan on the marketplace. Specifically, most individuals and families must find their plan during the yearly open enrollment period. The federal open enrollment period is from November 1 to December 15, with coverage to start the following year.

Yet while many people find a health care plan during the open enrollment period, there are still ways to get health care coverage outside of that period. Ultimately, you will need to qualify for a special enrollment period (“SEP”).

In this post, we want to further discuss how you can get coverage outside of open enrollment periods through an SEP. By exploring this topic, you will be in a much better position to determine whether you are eligible for health care enrollment through an SEP.

SEP Basics: Determining Eligibility

At its core, an SEP gives you a specific period of time to purchase a health care plan outside of the traditional open enrollment period. There are several different types of SEPs, and most of them occur due to major life changes. Therefore, if you are looking for health care coverage beyond that November 1 through December 15 open enrollment period, your first step is determining whether you qualify for one of these SEPs. Also, you may notice that we frequently say that you may qualify. While you may have a good argument that you should be eligible for an SEP, the only way to know if you qualify is to apply for coverage.

The first SEP involves a change in household. Specifically, in the past 60 days, you may qualify if you got married, had a baby, adopted a child, placed a child for foster care, got divorced or legally separated and lost your health insurance, or if someone on your health care marketplace plan has died. In these situations, you will want to read the fine print to determine when the coverage will start. For instance, if you just got married, you can pick a health care plan by the last day of the month and then have your coverage start on the first day of the succeeding month. If you just had a child, your coverage can start on the day of the event itself. You can click here to see when your coverage would start for every scenario.

Next is a change in residence. If you have just moved, you may be able to purchase a health care plan through this SEP. The household moves that qualify under this SEP include moving to a new ZIP code or county and moving to the United States from a foreign country or U.S. territory. If you are a student, you may qualify if you move to or from the place you attend school. You may qualify for this SEP if you are moving to or from a shelter or other transitional housing. Finally, seasonal workers are eligible for this SEP if they are moving to or from the place that they live and work. Notably, this SEP isn’t available to those who stay somewhere for vacation or are moving solely for medical treatment.

From changes in residence, there is a SEP for those who have lost health insurance. Specifically, you or anyone in your household must have lost qualifying health coverage in the past 60 days. You may also qualify if you expect to lose qualifying health coverage in the next 60 days. Besides timing, you may be eligible under this SEP if you have lost job-based health care coverage or lost individual health care coverage for a policy that you purchased yourself. If you have lost eligibility for Medicaid, Children’s Health Insurance Program (“CHIP”), or Medicare, you may also be eligible. Finally, if you have lost coverage through a family member, you may be eligible.

The fourth SEP exists if an employer offers to help with the cost of your health care coverage. You may be eligible for this SEP if you (or anyone else in your household) recently gained access to an individual coverage Health Reimbursement Arrangement (“HRA”) or a so-called Qualified Small Employer Health Reimbursement Arrangement (“QSEHRA”). This must have occurred in the last 60 days or you must expect it to occur in the next 60 days. You can read more about the specifics of this SEP here, but the bottom line is that you may be able to purchase health insurance under these types of scenarios.

Finally, there is a fifth SEP that has various other qualifying changes. For instance, you may qualify for this SEP if recently became a U.S. citizen. You may qualify if you are leaving incarceration or are starting (or ending) service as an AmeriCorps State and National, VISTA, or NCCC member. And you may also be eligible if you are gaining membership in a federally-recognized tribe or have status as an Alaska Native Claims Settlement Act (“ANCSA”) Corporation shareholder. Click here to learn more about these qualifying changes.

SEP Basics: Applying for Coverage

These are the five broad categories of SEPs. To reiterate, while you may strongly believe that one of these SEPs applies to you, the only way to be completely sure is to apply for health care coverage. To be clear, you want to read the fine print, as certain SEPs may require you to apply 60 days before an event occurs or 60 days after. The unfortunate news is that if you miss your specific application period, you may need to wait for the next open enrollment period to apply. If that occurs (or if you are not eligible for any of these SEPs), you can apply for a 2021 health plan starting on November 1, 2020. Your last opportunity would be on December 15, 2020. Importantly, if you are seeking CHIP or Medicaid coverage, you are eligible throughout the year. This is true whether or not you qualify for a specific SEP.

When you submit your application, you will need to supply basic information about yourself and members of your household. But along with this, you may need to submit documents that show you are eligible for a specific SEP. For instance, if you moved to a different state, you may need to show proof of your new address. Simply follow the instructions provided and attest that all of the information that you have submitted is true.

Upon submitting your application, you will quickly be able to determine whether you are eligible to purchase health care coverage. If you are turned down and still think that you can qualify, you can choose to appeal the decision.

In the end, all hope isn’t lost if you missed this year’s open enrollment period. Feel free to do some additional research to see if you qualify for a SEP. Doing so, you will be able to purchase high-quality health insurance sooner than you may think.

© 2020 PA Health Advocates, LLC

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