A Special Enrollment Period (SEP) allows individuals to enroll in ACA Marketplace health coverage or switch plans outside of the annual Open Enrollment Period (OEP). Clients may qualify based on specific life events known as qualifying life events. The qualifying events and eligibility rules in this article reflect current CMS guidelines for the ACA Marketplace.
Change in Primary Place of Living
A client or anyone in their household may qualify for a SEP 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, returning to the U.S. from abroad, leaving incarceration, and moving to or from a location where the client attends school, works seasonally, or lives in transitional housing or a shelter. The client generally must have had qualifying health coverage for at least 1 day in the 60 days before the move.
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 SEP due to a change in household size. Qualifying household changes include:
Marriage (at least one spouse must generally have had qualifying health coverage for at least 1 day in the 60 days before the marriage)
Birth of a child
Adoption or placement for adoption
Placement in foster care
Court-ordered dependent coverage changes
Death of a household member that results in loss of coverage
Loss of Health Coverage
A client or anyone in their household may qualify for a SEP if they lost qualifying health coverage, also called Minimum Essential Coverage (MEC). This includes:
Loss of employer-sponsored coverage
Loss of Medicaid or CHIP eligibility
Loss of Medicare Part A or Medicare Advantage (Part C)
Aging off a parent's plan (including when a client turns 26)
End of COBRA coverage — note that losing COBRA because it naturally ended qualifies, but voluntarily dropping COBRA does not
Loss of individual health coverage
Clients may report a loss of qualifying health coverage up to 60 days before or after the loss. 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 may qualify for a SEP if they experience a change that affects their eligibility for Marketplace coverage, Premium Tax Credits (APTC), or Cost-Sharing Reductions (CSR). Examples include becoming a U.S. citizen or gaining lawful presence status, being released from incarceration, or gaining status as a member of a federally recognized Tribe or ANCSA Corporation shareholder.
An income change alone does not automatically qualify a client for a SEP. Per CMS guidelines, the change must result in a recognized eligibility change — such as becoming newly eligible or ineligible for APTC or CSR — to create SEP eligibility.
Marketplace Errors or Misconduct
A client may qualify for a SEP if they were not enrolled in a plan, or were enrolled in the wrong plan, due to misinformation, misconduct, or inaction by an agent, broker, assister, or enrollment entity acting in an official capacity, a Marketplace or CMS system error, or incorrect plan data displayed on HealthCare.gov at the time of plan selection.
American Indians and Alaska Natives
Members of a federally recognized Tribe and ANCSA Corporation shareholders can enroll in a Marketplace plan at any time during the year without needing a qualifying life event.
Exceptional Circumstances
CMS may grant a SEP based on exceptional circumstances on a case-by-case basis. Examples include:
Natural disasters
Serious medical conditions that prevented enrollment
Domestic violence or spousal abandonment
Applying for Medicaid or CHIP and being determined ineligible after Open Enrollment ended
Newly gaining access to an ICHRA or QSEHRA
AmeriCorps service members starting or ending service
Other circumstances determined by CMS
SEP Document Verification
After submitting an application, a client may be asked to submit documents to confirm the events that qualify them for a SEP. The client has 30 days to send acceptable documents. Coverage starts based on when they pick a plan, but the client cannot use their coverage until documents confirm eligibility and they pay their first premium.
Source
The qualifying events and eligibility rules in this article are based on CMS guidelines for the ACA Marketplace. For the most current information, refer to healthcare.gov or the applicable CMS published guidance.
Additional Resources
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