What is a special enrollment period?
Health Benefits • May 28, 2024 at 9:30 AM • Written by: Holly Bengfort
When it comes to health insurance, you typically have one small window of time to sign up. The open enrollment period runs from November through January in most states. It's the designated time of year for Americans to make changes to their current policies or enroll for the first time in individual marketplace coverage.
This set time frame keeps people from signing up for an insurance plan only after they get sick or injured. But don't worry; if life throws an unexpected curveball your way, you may qualify for an enrollment exception. For example, you can participate in a special enrollment period (SEP) if you age out of a parent's plan or have a baby.
In this article, we'll explain what an SEP is, what life events qualify you for one, and what to do once you do qualify.
Takeaways from this blog post:
- A special enrollment period (SEP) allows individuals to make changes to their health insurance outside of open enrollment due to qualifying life events.
- Qualifying events for an SEP include loss of comprehensive health coverage, offer of new health benefits, changes in household, and changes in residence.
- Low-income households may qualify for an SEP outside of the normal open enrollment period for health coverage.
When is open enrollment for health insurance?
It's important to know what the open enrollment calendar looks like so you're not caught off guard when it comes to your coverage. By being aware of these important dates, you'll know when you'll be able to freely enroll in or change your health insurance policy. If open enrollment ends before you can make your adjustments, that's when you'll need to qualify for an SEP.
Here's a breakdown of the important open enrollment dates:
- November 1: This is when open enrollment starts for health coverage for the next plan year in most states. This is when you can enroll in, re-enroll in, or change your health plan selection through the federal Health Insurance Marketplace.
- December 15: This is the last day you can enroll in or change plans for your coverage to start on January 1. Open enrollment also ends in Idaho on this date.
- January 15: This is when open enrollment officially ends for most states, though some extend open enrollment through the end of the month.
- February 1: Coverage starts for those who enroll in or change plans from December 16 through January 15 and pay their first monthly premium.
It’s important to note that the open enrollment period defined above typically only applies to individuals who are trying to enroll in an individual marketplace policy. If you’re covered by an employer-sponsored group plan, your open enrollment period may vary.
How does an SEP work?
It takes a major life change to qualify for an SEP. This is when you can make changes to your health insurance plan even though it's not an open enrollment period as defined by the Affordable Care Act (ACA). Keep in mind that if you qualify for Medicaid or the Children's Health Insurance Program (CHIP), you're eligible to enroll at any point in the year.
Certain qualifying events and exceptional circumstances will activate an SEP, allowing you to change your health coverage for a certain period following the triggering event. Generally speaking, you'll have a 60-day special enrollment period after the event to enroll in a new health plan through federal or state-based marketplaces.
If you don't make the necessary changes to your health insurance during the SEP, you may have a gap in coverage or have to wait until the next open enrollment period for the following health plan coverage year.
How do I know if I qualify for an SEP?
To qualify for an SEP, you need to have a qualifying life event occur.
There are four basic types of qualifying events:
- Loss of health coverage
- Offer of new health benefit
- Changes in household
- Changes in residence
Loss of coverage
This includes losing employer-sponsored coverage, student health plan coverage, and eligibility for Medicaid or CHIP. Aging out of your parent's plan is also a loss in coverage. You'll lose your dependent status and access to your parent’s plan when you turn 26. If your current insurance coverage or individual market plan no longer exists, you also fall under this qualifying life event.
It's important to note that voluntary cancellation of coverage doesn't count as a qualifying life event.
Offer of a new health benefit
If your employer offers a new health benefit, the marketplaces consider it a qualifying event.
Specifically, if your employer offers you a health reimbursement arrangement (HRA) for the first time, such as the qualified small employer HRA (QSEHRA) or individual coverage HRA (ICHRA), you can enroll in marketplace coverage within 60 days.
Changes in household
The marketplaces accept several scenarios under this qualifying event. If you get married, have a baby, adopt a child, or place a child in foster care, you may qualify for a SEP. This also applies to people who got divorced or went through legal separation and lost their current coverage. If someone in your family died and you lost health insurance coverage as a result, that would also be considered a change in the household. Remember, situations involving a domestic partnership vary from state to state.
Changes in residence
Most forms of relocation count as a qualifying life event. If you're moving to a new ZIP code or to the United States from another country or a U.S. territory, you can enroll in or change your health coverage. This also covers students who move to or from where they attend school. Seasonal workers also fall under this category if they move to or from the place where they live and work. Keep in mind that moving for medical treatment options doesn't qualify you for an SEP.
Additional qualifying changes for an SEP
Other circumstances that allow you to change your health coverage include experiencing an enrollment or policy information display error, gaining or becoming a dependent due to child support, or getting an SEP appeal decision that's in your favor. Survivors of domestic abuse are also eligible for an SEP to enroll in a health plan that's separate from their abuser. Those who leave incarceration may also become eligible for an SEP.
Additionally, you'll qualify if you gain membership in a federally recognized tribe, become an Alaska Native Claims Settlement Act (ANCSA) Corporation shareholder, or begin or end service with AmeriCorps State, AmeriCorps National, VISTA, or NCCC.
You could also qualify for an SEP if you previously qualified in the previous 60 days but missed your enrollment deadline for health plan coverage due to a natural disaster or a national or state-level emergency1.
Finally, you may become eligible for an SEP if you participate in your employer’s group health plan and it either becomes unaffordable or stops providing minimum value. However, you must be able to drop your employer-sponsored coverage to take advantage of the SEP.
Your group plan is unaffordable if you must pay more than 8.39% of your household income in 2024 for premiums.
Special enrollment for families with a low household income
For people who may be struggling financially, the low-income SEP gives them access to find affordable health coverage outside of the normal open enrollment period.
In September 2021, the U.S. Department of Health & Human Services (HHS) established this SEP for households with an annual income of less than 150% of the federal poverty level (FPL), as long as the applicant is also eligible for premium tax credits that cover the cost of a benchmark plan.
The SEP was specifically created to make it easier for low-income Americans to enroll in ACA-compliant plan coverage throughout the year instead of just during open enrollment or when they experience a qualifying life event. This gives them the opportunity to carefully consider their choices or seek assistance in finding a suitable, qualified health plan.
According to HealthInsurance.org2, if you're a single person who's enrolling for coverage in 2024, an income of no more than $21,870 amounts to 150% of the poverty level. It's $52,710 for a household of five people.
If you're not sure if you're eligible, there are several online tools available to help you calculate whether or not you qualify for premium tax credits, and in turn, qualify for the low-income SEP. KFF's Health Insurance Marketplace Calculator3 is one option.
I qualify for an SEP; now what?
If you've experienced one of the qualifying events listed above, you're ready to apply for an SEP. You can do this either through HealthCare.gov4 or your state exchange5.
Your application will differ depending on whether you've experienced a qualifying life event or had another special circumstance that will affect your health coverage.
If you've experienced a qualifying life event, you can apply online. You can check to see if your life event qualifies by going to HealthCare.gov and answering a few screening questions6 to see if you qualify for an SEP.
If you have a special circumstance rather than a qualifying life event, you'll want to contact the marketplace coverage call center directly at 1-800-318-2596. A representative will ask a few questions about your situation to help decide if you're eligible for an SEP.
If I believe I qualify but was turned down, what steps should I take?
If you believe that you should qualify for an SEP, but your request was denied, you can submit an appeal. You have 90 days to ask for an appeal. Even if you miss the 90-day timeframe, don't lose hope. There's a chance you could get an extension. When filing your appeal, you should explain why you missed the deadline.
Conclusion
While the annual open enrollment period is the ideal time to sign up for individual coverage health insurance, you have options for when life gets complicated. If you're experiencing an unexpected life event, a special enrollment period (SEP) exists to make sure your health insurance coverage remains intact.
This blog article was originally published on August 1, 2019. It was last updated on May 28, 2024.
1. https://www.healthcare.gov/sep-list/
3. https://www.kff.org/interactive/subsidy-calculator/
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Holly Bengfort
Holly is a content marketing specialist for PeopleKeep. Before joining the team in 2023, Holly worked in television news as a broadcast journalist. As an anchor and reporter, she communicated complex stories to the vast communities she served on a daily basis. Her background has given her a greater understanding of people and the issues that affect our lives. When Holly isn’t writing, she enjoys reading, exercising, and spending time at the beach.