Missed Open Enrollment? You May Qualify for a SEP!
What is a SEP?
SEP stands for Special Enrollment Period. It’s a time outside the Health Insurance Marketplace® annual Open Enrollment Period when you can enroll in health insurance. You can enroll in Medicaid or CHIP at any time but once outside of the OEP, you need a SEP for health insurance.
How can I qualify for a SEP?
You must experience one of many Qualifying Life Events (QLEs) to be eligible for a SEP and you must request it within a specific time window before/after the event occurs. The time window will vary depending on the type of SEP (usually 60 days before or 60 days after the event).
QLE definition
A QLE (qualifying life event) is a major change in your circumstances, either planned or unplanned) that can impact your insurance needs to such a degree that existing coverage is no longer suitable. The SEP (special enrollment period) provided due to a QLE gives you the chance to update your information and make appropriate changes to your plan to accommodate the change in circumstances without having to wait until the next Open Enrollment Period.
If you’re not sure whether or not you qualify, this screening tool from HealthCare.gov can help: Find out if you can get health coverage now
Life changes
Life changes that may qualify for a SEP (such as changes in household or residence, loss of health coverage, or other qualifying changes) are detailed in the drop-down section below. For loss of health coverage, SEP details depend on the type of coverage lost. You may qualify for a SEP if you or anyone in your household lost qualifying health coverage in the past 60 days OR expects to lose coverage in the next 60 days.
If you lost Medicaid or CHIP coverage in the past 90 days, you may qualify for a SEP.
Changes in household
You may qualify for a SEP if in the past 60 days you or anyone in your household:
- Got married. Pick a plan by the last day of the month and your coverage can start the first day of the next month.
- Had a baby, adopted a child, or placed a child for foster care. Your coverage can start the day of the event, even if you enroll in the plan up to 60 days afterward.
- Got divorced or legally separated and lost health insurance. Divorce or legal separation WITHOUT losing coverage doesn’t qualify for a SEP.
- Died. You’ll qualify for a SEP if someone included on your Marketplace plan dies which causes you to lose your current health plan.
Changes in residence
You may qualify for a SEP if you move to:
- A new home in a new ZIP code or county
- The U.S. from a foreign country or United States territory
Or, move to or from the:
- Place you attend school (if you’re a student)
- Place you both live and work (if you’re a seasonal worker)
- Shelter or other transitional housing
Moving only for medical treatment or staying somewhere for vacation doesn’t qualify you for a SEP.
You must prove you had qualifying health coverage for one or more days during the 60 days before your move. You don’t need to provide proof if you’re moving from a foreign country or United States territory.
Loss of job-based coverage
You may qualify for a SEP if you lose health coverage through your employer or the employer of a family member, including if you lose coverage through a parent or guardian because you’re no longer a dependent.
- If you choose to drop coverage you have as a dependent, that alone DOESN’T qualify you for a SEP. You must also have a decrease in household income or change in your previous coverage that made you eligible for savings on a Marketplace plan.
Loss of individual health coverage
You may qualify for a SEP if you lose individual health coverage, including if:
- Your individual plan or your Marketplace plan is discontinued (no longer exists).
- You lose eligibility for a student health plan.
- You lose eligibility for a plan because you no longer live in the plan’s service area.
- Your individual or group health plan coverage year is ending in the middle of the calendar year, and you choose not to renew it.
- Your household income decreased, and now you qualify for savings on a Marketplace plan.
You WON’T qualify for a SEP if you lost coverage because you didn’t provide required documents. (Details about sending documents: Why the Marketplace asks for more information | HealthCare.gov)
Employer offer to help with the cost of coverage
You may qualify for a SEP to enroll in Marketplace coverage if you (or anyone in your household) were offered an individual coverage HRA (Health Reimbursement Arrangement) or a Qualified Small Employer Health Reimbursement Arrangement (QSEHRA) in the past 60 days OR expect to in the next 60 days.
Your employer may refer to an individual coverage HRA by a different name, like “ICHRA.”
Get details about individual coverage HRAs and Qualified Small Employer HRAs.
If you qualify, contact the Marketplace Call Center (1-800-318-2596) to complete your enrollment. You can’t do this online.
Other situations that may qualify you for a SEP include:
- 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
- Starting or ending service as an AmeriCorps State and National, VISTA, or National Civilian Community Corps (NCCC) member
- Being affected by an unexpected and uncontrollable event or natural disaster (like an earthquake, massive flooding, or a hurricane)
Other Special Enrollment Periods
- Unexpected situations (serious medical condition, natural disaster, or state-level emergency)
- Enrollment or plan information display errors
- Becoming newly eligible for savings on a Marketplace plan
- Found not eligible for Medicaid or CHIP coverage
- Gaining or becoming a dependent due to a court order
- Domestic abuse/violence or spousal abandonment
- Successful appeal decision
If you think you qualify for a Special Enrollment Period
Contact the Marketplace Call Center at 1-800-318-2596 (TTY: 1-855-889-4325)
They’ll ask for information about your situation and see if you qualify for a SEP. If so, they’ll help you apply and enroll in coverage.
If you’re already enrolled in a plan and you get a SEP, you can stay in your current plan (in most cases) or switch plans. In some limited cases, you may qualify for an earlier start date of coverage. NOTE: Remember that you must pay your first premium payment before your coverage starts.
Filing an appeal
If the Marketplace denies your request for a SEP, you can file an appeal if you disagree with the decision. If your appeal is successful, you can get coverage back to the date your SEP was denied.
More about how to file an appeal
Health Insurance Marketplace® is a registered service mark of the U.S. Department of Health & Human Services.
