Sometimes you experience a big life change that also changes your health coverage needs. If your circumstances change during the year, you may qualify for a Special Enrollment Period (SEP) that lets you apply for Marketplace coverage or change your existing plan outside of Open Enrollment.
This searchable FAQ resource features all the information in our SEP Fact Sheet as well as questions commonly asked during ACE TA Center webinars. The FAQs provide details on life events and special circumstances that may qualify an individual for a SEP, as well as information about what to do if they think they are eligible. FAQs and answers are arranged into nine categories:
- SEP Basics
- COBRA-Related
- Employer Health
- Eligibility for Moving
- Newly Eligible
- Disaster-related
- Traumatic Life Event
- Marketplace-related events
- Ineligibility for SEP
Special Enrollment Period Basics
Download FAQs: Special Enrollment Periods for Marketplace Health Coverage
What is a Qualifying Life Event?
“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.
Source: ACE TA Center
Date Published: 09/12/2024
How long does a client have after a Qualifying Life Event to enroll into a Marketplace plan?
In 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.
Source: ACE TA Center
Date Published: 09/12/2024
When does coverage begin after a client chooses a new Marketplace plan?
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.
Source: ACE TA Center
Date Published: 09/12/2024
Can a client enroll in a Marketplace health insurance plan outside of Open Enrollment?
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.
Source: ACE TA Center
Date Published: 09/12/2024
What changes in life circumstances (e.g., change in income) make an individual eligible for a SEP?
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.
Source:
Date Published: 09/18/2024
COBRA-Related SEP
My client recently reported their COBRA coverage expired. Do they qualify for a SEP?
Yes, this constitutes a qualifying life event and the client is eligible for a SEP.
Source: ACE TA Center
Date Published: 09/12/2024
If an employer stopped contributing to COBRA coverage, is that person eligible for a SEP?
Yes, if an employer stopped contributing to COBRA coverage, a SEP is allowable.
Source: ACE TA Center
Date Published: 09/12/2024
Employer Health SEP
What does it mean if an employer health plan no longer meets “affordability” and “minimum value” standards due to an increase in the amount one may have to pay or a change in a client’s household income?
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.
Source: ACE TA Center
Date Published: 09/12/2024
SEP Eligibility for Moving
When does moving give a person eligibility 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.
Source: ACE TA Center
Date Published: 09/20/2024
Newly Eligible SEP Coverage
If someone gains or maintains status as a member in a federally-recognized Native American or tribe or Alaska Native Claims Settlement Act Corporation shareholder, are they eligible for an SEP?
Yes, membership in a federally-recognized Native American or tribe or Alaska Natve Claims Settlement Act Corporation shareholder constitutes eligibility for a SEP.
Source: ACE TA Center
Date Published: 09/12/2024
If someone becomes newly eligible or ineligible for Advance Premium Tax Credits (APTCs) due to a change in household size or income, are they eligible for a SEP?
Yes, APTC eligibility or ineligibility constitutes eligibility for a SEP.
Source: ACE TA Center
Date Published: 09/12/2024
If someone becomes newly eligible for Cost-Sharing Reductions (CSRs), or becomes eligible for a different CSR level, due to a change in household size or income, are they eligible for a SEP?
Yes, changes to CSR constitutes eligibility for a SEP.
Source: ACE TA Center
Date Published: 09/12/2024
If one is released from incarceration are they eligible for a SEP?
Yes, being released from incarceration constitutes eligibility for a Marketplace Plan via a SEP.
Source: ACE TA Center
Date Published: 09/12/2024
If one gains a “lawfully present” immigration status, are they eligible for a SEP?
Yes, gaining a “lawfully present” immigration status constitutes eligibility for a Marketplace Plan via a SEP.
Source: ACE TA Center
Date Published: 09/12/2024
If someone’s income is at or below 150% FPL and is eligible for APTCs (available through the 2025 plan year), are they eligible for a SEP?
Yes, income below 150% and eligible for APTCs constitutes eligibility for a SEP.
Source: ACE TA Center
Date Published: 09/12/2024
If someone moves out of the “Medicaid coverage gap,” are they eligible for a SEP?
Yes, moving out of the Medicaid coverage gap constitutes eligibility for a SEP.
Source: ACE TA Center
Date Published: 09/12/2024
Disaster-related SEP
My client lives in an area that was impacted by a FEMA-declared disaster. As a result, my client was not able to enroll into a Marketplace plan during open enrollment. Could they qualify for a SEP due to the impact of the FEMA-declared disaster?
Yes, living in an area impacted by a FEMA-declared disaster constitutes eligibility for a SEP.
Source: ACE TA Center
Date Published: 09/12/2024
Traumatic Life Event SEP
My client has experienced domestic abuse, domestic violence, or spousal abandonment, and now wants to enroll in their own health plan separate from their abuser or spouse. Are they eligible 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.
Source: ACE TA Center
Date Published: 09/12/2024
Marketplace-related SEP events
My client applied for Medicaid or CHIP during Open Enrollment or a Special Enrollment Period and their state Medicaid or CHIP agency determined that they weren’t eligible after the enrollment period ended. Are they eligible for an SEP?
Yes, being ineligible for Medicaid or CHIP constitutes eligibility for a SEP.
Source: ACE TA Center
Date Published: 09/12/2024
What if my client experienced a technical error or other Marketplace-related issue preventing timely enrollment in the plan of their choice (e.g., enrolled in the wrong plan; received incorrect information from the Marketplace, a broker, or an enrollment assister; the Marketplace website had incorrect information about plan benefits, network, or costs). Are they eligible for a SEP?
Yes, a technical error constitutes eligibility for a SEP.
Source: ACE TA Center
Date Published: 09/12/2024
The Marketplace terminated my client’s coverage because they missed a deadline to provide additional documents verifying eligibility, but they eventually submitted the documents after the deadline had passed and were found eligible. Are they eligible for a
Yes, termination of coverage because of a missed deadline to provide additional documents that determine the client is eligible constitutes eligibility for a SEP.
Source: ACE TA Center
Date Published: 09/12/2024
What if my client’s Marketplace plan significantly violated its contract with the client?
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.
Source: ACE TA Center
Date Published: 09/12/2024
What if my client wins a Marketplace appeal because they received an incorrect eligibility determination or an incorrect coverage effective date?
Your client is eligible to enroll in a Marketplace plan via a SEP based on the won appeal.
Source: ACE TA Center
Date Published: 09/12/2024
Ineligibility for SEP
My client voluntarily canceled their health coverage. Would they qualify for a SEP?
No, a client cancelling their own health coverage does not constitute eligibility for a SEP.
Source: ACE TA Center
Date Published: 09/12/2024
My client lost coverage because they did not pay their monthly health insurance premium on time. Would they qualify for a SEP?
No, lack of timely premium payments does not constitute eligibility for a SEP.
Source: ACE TA Center
Date Published: 09/12/2024
My client committed insurance fraud on their application. Would they qualify for a SEP?
No, comiting insurance fraud does not allow a client eligibility for a SEP.
Source: ACE TA Center
Date Published: 09/12/2024
