FAQs: Special Enrollment Periods for Marketplace Health Coverage

Yes, there are times when a client is able to enroll in a Marketplace plan outside of Open Enrollment. When a client experiences a big life change that also changes their health coverage needs—like having a child, changing jobs, or losing health coverage, that person may qualify for a Special Enrollment Period (SEP), which allows a person to apply for Marketplace coverage or change their existing Marketplace coverage outside the annual Open Enrollment period. A client may also qualify for a SEP if something happened during Open Enrollment that prevented them from getting the right coverage.

“Qualifying life events” are changes in a person’s life circumstances that can make them eligible for a SEP through Healthcare.gov. More than one SEP may apply to a person’s situation.

IIn most cases, a client has 60 days after the date of a qualifying life event to enroll in a Marketplace plan or make changes to your existing coverage.

Coverage usually begins the first day of the month after you choose your new plan. For example, if a person chooses a new Marketplace plan on June 15, their coverage will begin on July 1.

The following changes in life circumstances are qualifying life events that make a client eligible for a SEP:

• Loss of income.
• Loss of employment/reduced hours.
• Change in marital status.
• Loss of dependent status.
• Turning the age of 26 and loss of coverage through a parental policy.
• Loss of eligibility for a student health plan.
• Health plan no longer available.

See also this explanation at Healthcare.gov.

Yes, this constitutes a qualifying life event and the client is eligible for a SEP.

Yes, if an employer stopped contributing to COBRA coverage, a SEP is allowable.

If an employer health plan no longer meets affordability and minimum value standards due to an increase in what one has to pay or a change in household income, they are eligible for a SEP.

• Moving to new place (city, county, state, or moving to the U.S. from abroad).
• Moving in with parents or other relatives as a dependent.
• Moving to or from a shelter or other transitional housing.
• Moving for seasonal employment.

Yes, being released from incarceration constitutes eligibility for a Marketplace Plan via a SEP.

Yes, APTC eligibility or ineligibility constitutes eligibility for a SEP.

Yes, changes to CSR constitutes eligibility for a SEP.

Yes, moving out of the Medicaid coverage gap constitutes eligibility for a SEP.

Yes, membership in a federally-recognized Native American or tribe or Alaska Natve Claims Settlement Act Corporation shareholder constitutes eligibility for a SEP.

Yes, income below 150% and eligible for APTCs constitutes eligibility for a SEP.

Yes, gaining a "lawfully present" immigration status constitutes eligibility for a Marketplace Plan via a SEP.

Yes, living in an area impacted by a FEMA-declared disaster constitutes eligibility for a SEP.

Yes, experiencing domestic abuse, violence, or abandonment and wanting to enroll in one's own health plan constitutes eligibility for a SEP.

If your client beleives their health plan did not follow the terms of your contract, contact the Marketplace Call Center to see if your client is eligible to enroll into a different health plan.

Your client is eligible to enroll in a Marketplace plan via a SEP based on the won appeal.

Yes, being ineligible for Medicaid or CHIP constitutes eligibility for a SEP.

 Yes, a technical error constitutes eligibility for a SEP.

Yes, termination of coverage because of a missed deadline to provide additional documents that determine the client is eligible constitutes eligibility for a SEP.

 No, a client cancelling their own health coverage does not constitute eligibility for a SEP.

No, lack of timely premium payments does not constitute eligibility for a SEP.

No, commiting insurance fraud does not allow a client eligibility for a SEP.