A Special Enrollment Period (SEP) allows individuals to enroll in ACA Marketplace health coverage or switch plans outside of the annual Open Enrollment Period. Clients may qualify for a Special Enrollment Period based on specific life events known as qualifying life events.

Agents should be familiar with all SEP qualifying events to help clients enroll in coverage when they experience a life change outside of Open Enrollment.

Change in Primary Place of Living

A client or anyone in their household may qualify for a Special Enrollment Period if they had a change in primary place of living and gain access to new Marketplace health plans. Qualifying moves include moving to a new ZIP code or county, moving to the U.S. from a foreign country or U.S. territory, and moving to or from a location where the client attends school, works seasonally, or lives in transitional housing.

The client generally must have had qualifying health coverage for at least 1 day in the 60 days before the move. This prior coverage requirement does not apply if the client was living in a foreign country or U.S. territory, is a member of a federally recognized Tribe or ANCSA Corporation shareholder, or lived in a service area with no available qualifying Marketplace coverage.

Moves for medical treatment only or vacation stays do not qualify for a Special Enrollment Period.

Change in Household Size

A client or anyone in their household may qualify for a Special Enrollment Period if they got married, had a baby, adopted a child, placed a child for foster care, or gained or became a dependent due to a child support or other court order.

For marriage, generally one spouse must have had qualifying health coverage for at least 1 day in the 60 days before the marriage. The same exceptions apply as with the change in residence SEP (foreign country, Tribe membership, or no available coverage in the service area).

Loss of Health Coverage

A client or anyone in their household may qualify for a Special Enrollment Period if they lost qualifying health coverage.

Examples of qualifying coverage that can trigger this SEP include:

Coverage through a job (including when an employer stops offering coverage or the coverage is no longer considered qualifying)
Medicaid or Children's Health Insurance Program (CHIP) coverage, including pregnancy-related and medically-needy coverage
Medicare Part A (Hospital Insurance) or Medicare Advantage (Part C) — Medicare Part B and Part D alone are not qualifying coverage
Individual health coverage that ended after a decrease in household income made the client newly eligible for Marketplace savings
Individual or group health plan coverage that ended mid-calendar year
Coverage under a parent's health plan (including when the client turns 26)

Clients may report a loss of qualifying health coverage up to 60 days before or after the loss of coverage. For Medicaid or CHIP, the client may report the loss up to 90 days after losing coverage.

Change in Eligibility for Marketplace Coverage or Financial Assistance

A client or anyone in their household may qualify for a Special Enrollment Period if they:

Are enrolled in Marketplace coverage and report a change that makes them newly eligible for financial assistance, newly ineligible for financial assistance, or eligible for a different amount of cost-sharing help
Become newly eligible for Marketplace coverage because they became a citizen, national, or lawfully present individual
Become newly eligible for Marketplace coverage after being released from incarceration
Gain or maintain status as a member of a federally recognized Tribe or ANCSA Corporation shareholder
Become newly eligible for Marketplace financial assistance because they moved to a different state and/or had a change in household income, and were previously ineligible for both Medicaid (in a non-expansion state) and Marketplace financial assistance (income below 100% FPL)

Enrollment or Plan Error

A client or anyone in their household may qualify for a Special Enrollment Period if they were not enrolled in a plan, or were enrolled in the wrong plan, because of misinformation, misrepresentation, misconduct, or inaction by someone working in an official capacity (such as an insurance company, navigator, certified application counselor, agent, or broker), a technical error or Marketplace-related enrollment delay, or incorrect plan data displayed on HealthCare.gov at the time of plan selection.

Clients may also qualify if they can prove their Marketplace plan violated a key part of its contract.

American Indians and Alaska Natives

Members of a federally recognized Tribe and Alaska Native Claims Settlement Act (ANCSA) Corporation shareholders can enroll in a Marketplace plan at any time during the year without needing a qualifying life event.

Other Qualifying Situations

A client or anyone in their household may also qualify for a Special Enrollment Period in the following situations:

Applied for Medicaid or CHIP through the Marketplace during Open Enrollment or because of a qualifying event, and the state agency determined they were not eligible after Open Enrollment ended or more than 60 days after the qualifying event
Is a victim of domestic abuse or spousal abandonment and wants separate coverage from the abuser or abandoner
Submitted documents requested by the Marketplace to confirm eligibility, but coverage had already ended after a failure to confirm eligibility
Has household income under 100% FPL, submitted documents to prove eligible immigration status, and did not enroll while waiting for document review
Is an AmeriCorps service member starting or ending service
Can show an exceptional circumstance (incapacitation, natural disaster, or other national or local emergency) prevented enrollment during Open Enrollment or another SEP window
Has newly gained access to an Individual Coverage HRA (ICHRA) or is newly provided a Qualified Small Employer HRA (QSEHRA)

SEP Document Verification

After submitting an application, a client may be asked to submit documents to confirm the events that qualify them for a Special Enrollment Period. The client has 30 days to send acceptable documents by uploading online or mailing copies (not originals).

The client's coverage starts based on when they pick a plan, but the client cannot use their coverage until their documents confirm they qualify for the SEP and they pay their first premium to the insurance company.