What is a Special Enrollment Period?

By HealthSherpa

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Sometimes, your life changes. And sometimes when it does, so can your health insurance. Enter the Special Enrollment Period (SEP), or a period when you can apply for new health insurance as a result of what’s known as a “Qualifying Life Event” (QLE). Getting married, welcoming a new baby, losing a job, or moving to a new state all launch an SEP. And this means you can shop for new coverage that best suits where you are in your life right now.

What exactly are Special Enrollment Periods?

If you qualify for a Special Enrollment Period (SEP), you can change plans or find a new plan on the Marketplace outside of the annual Open Enrollment Period for the upcoming year. Depending on the exact situation, this might mean that you can purchase a health insurance plan through the Marketplace. There are three general categories of qualifying life events that can trigger a Special Enrollment Period: Loss of health coverage, changes in your household, and changes in residence.

There is no such thing as a pre-set Special Enrollment Period in the United States. Rather, a Special Enrollment Period begins when a person has a qualifying event.

It’s also important to note, you can enroll in Medicaid or the Children’s Health Insurance Program (CHIP) any time of year, whether you qualify for a Special Enrollment Period or not.

Hoping to find out if you’re eligible for a Special Enrollment Period? You can use this handy SEP tool to determine if you qualify. Or you can reach out to the HealthSherpa Consumer Advocate team at (855) 772-2663.

How long does a Special Enrollment Period last?

You have 60 days following the Qualifying Life Event (QLE) to enroll in a new Marketplace plan. The clock starts the day you welcome a new baby, lose your job, move to a new state, or marry.

If you miss your SEP, you’ll have to wait to enroll in health insurance until the next year’s Open Enrollment Period. Typically, this starts on November 1st and runs through January 15th, in most states. 

What are qualifying life events for Special Enrollment Periods?

Life events that frequently qualify a person for a Special Enrollment Period fall into three general categories, plus exceptional circumstances:

Loss of health coverage

You might qualify for a Special Enrollment Period if you, a spouse, or parent lose your existing health coverage. If you lose your job, and your job-provided plan, you would likely qualify for an SEP. If you graduate and your student health plan through your school ends, you may qualify, too. You could qualify for an SEP if you lose Medicare, Medicaid or CHIP eligibility. And if you’re about to turn 26 and roll off of your parent’s health insurance plan, you may qualify for an SEP, too.

You won’t qualify for a Special Enrollment Period due to loss-of-coverage if you don’t pay your monthly premiums. So it’s a good idea to add a reminder to your phone, write it down on your calendar, or setup recurring payments to help make sure you stay insured. 

Changes in your household

If the number of people in your household has changed, that might mean you’re now eligible for an SEP. So if you got married or entered into a domestic partnership, you could be SEP-eligible. And if you got divorced or legally separated, you could be SEP-eligible, too. But changes in marital status aren’t the only qualifiers. If you had or adopted a baby, you may also now be SEP eligible. An SEP can be triggered by a change in your foster care placement. Same goes for aging out of the foster care system. You may also qualify for an SEP if you lose coverage due to a death of a family member.

A Special Enrollment Period may also begin if you gained or became someone else’s dependent. This applies as a result of marriage or a court order. In this scenario, though, one of the two spouses must have had qualifying health insurance for at least one day in the 60 days preceding the marriage to qualify for an SEP.

You’ll need to provide documentation if you apply for an SEP because of a change-of-household. To get coverage, you’ll need to prove your Qualifying Life Event. Keep any marriage licenses, birth certificates, or court orders on hand to ensure you have everything you need to apply.

Changes in residence

Lastly, you may also qualify for a Special Enrollment Period if you have a change in where you live. A ZIP code or county change could trigger an SEP, whether you’re moving within the same state or out-of-state. A student moving to or from the place where you attended school might qualify for one. Seasonal workers moving to or from the place you both live and work might make you eligible for an SEP too. And if you’re moving out of a shelter or other transitional housing, you might qualify, too.

If you’ve moved and had qualifying health insurance for at least one of the 60 days preceding your move, you can apply for a Special Enrollment Period. Then, you can start shopping on the Marketplace. (This won’t apply if you were living out of the country, in a U.S. territory, or if you’re a member of a federally recognized tribe or an Alaska native, and couldn’t get coverage where you were in the 60 days before your move.) Moving somewhere only for medical treatment or a vacation won’t qualify you for a Special Enrollment Period, though.

To make things easier, we created a FREE guide to highlight each type of qualifying life event. You can grab it here and save to your computer for future reference.

Exceptional circumstances

Outside of this, the other things that count as a qualifying life event that can trigger a Special Enrollment Period are changes in your income that affect the coverage you qualify for, gaining membership in a federally recognized tribe or status as an Alaska Native Claims Settlement Act (ANCSA) Corporation shareholder, becoming a U.S. citizen, leaving incarceration (jail or prison), and AmeriCorps members starting or ending their service.

There are also some forms of more exceptional circumstances that might qualify you for a Special Enrollment Period. These exceptional circumstances include natural disasters or experiencing domestic violence. You can learn more about these additional circumstances at HealthCare.gov or by contacting the HealthSherpa Consumer Advocate team.

You can also find a full list of qualifying life events here.

How do I find out if I’m eligible for an SEP?

If you think you may be eligible for a Special Enrollment Period because of a qualifying life event, you can use HealthSherpa’s screener tool. This will let you know if you qualify within minutes. And then if you’re eligible, you can start comparing health insurance plans. But don’t forget, you must apply for a new plan before the last day of your 60 day window.

How do I enroll during a Special Enrollment Period?

To apply for a health insurance plan during a Special Enrollment Period, you must first verify that you have a Qualifying Life Event. Then, you can apply for health insurance on the Health Insurance Marketplace either through HealthSherpa, HealthCare.gov or your state based Marketplace. If you’re looking for help over the phone, the HealthSherpa Consumer Advocate team is well-trained to help you assess your Special Enrollment Period eligibility. They can also compare your Marketplace plan options and get you enrolled in a plan that best serves your health and financial needs.

Do I need to submit documents to confirm my qualifying life event?

If you’re enrolling in a health insurance plan during a Special Enrollment Period, there are a few extra steps. Unlike Open Enrollment, the government and your insurance company will need documentation to verify a QLE. You can expect to receive an “Eligibility Results Notice” that details the type of documents needed to finalize your enrollment.

You will need documentation that clearly states when the QLE took place. For example, if you’re moving, you can supply bills, leases, or a letter from your previous insurance company. If you lose your insurance because of job loss, you can provide a letter from your former employer. With marriages and the birth or adoption of children, you need to provide documentation such as birth certificates, marriage licenses, and adoption papers.

The type of documentation you will need varies on your circumstances, and from state to state. You can see a complete list of documentation needed to enroll in a Special Enrollment Period at HealthCare.gov.

When does my coverage start after a Special Enrollment Period?

You have 30 days after you pick your plan to submit the requested documents. Once you get your SEP verification, you can make the first payment on your health insurance premium.

Coverage begins the following month after you enroll in a health insurance plan. So, if you enroll in a plan on July 15th, your coverage will begin on August 1st.

Also keep in mind that QLEs related to welcoming a new child, whether through childbirth or adoption, start with that child’s birth or day of adoption. As a result, when you complete your insurance application within the 60-day window of the SEP, as soon as your first premium is paid and the coverage is effective, it will also immediately retroactively cover the dates preceding it. That ensures that your new addition is covered from the day you welcome them into your family.

While unexpected events, such as job loss, happen, many qualifying life events are situations you can plan for, such as marriage, the birth or adoption of a child, and moving to a different state. To avoid a gap in coverage, begin considering your health insurance options 90 days before a qualifying life event. That way you can begin the enrollment process on the first day of your 60-day window. This will ensure you can enroll in your new health insurance plan as quickly and smoothly as possible.

What happens if I miss my Special Enrollment Period?

If you qualify for a Special Enrollment Period and miss your 60-day mark, you will have to wait until the next Open Enrollment Period to purchase health insurance, unless you have another qualifying life event before then. However, if your household income is low, you may qualify for Medicaid or the Children’s Health Insurance Program (CHIP). Both programs allow enrollment at any time during the year.

While the Affordable Care Act no longer requires that all Americans enroll in a health insurance plan, there’s really no reason to go without health insurance in the United States. And there are programs such as Medicaid and Medicare, which offer health insurance to low income and senior adults, as well as their qualifying family members. If you think you’re eligible for a Special Enrollment Period, or would like to check out your Medicaid or Medicare options, visit HealthSherpa for more information.