What Qualifies As A Special Enrollment Period

What Is A Special Enrollment Period Or Sep

Do You Qualify for a Special Enrollment Period?

Generally, you can only enroll in a health plan during open enrollment. After the Open Enrollment Period, you’re locked in to your health plan unless you’ve had a major life change or “qualifying life event” . Your life change or qualifying event allows you to enroll in a new health plan during what’s called a special enrollment period, or SEP. If you qualify for an SEP, you’re allowed to change your health plan or apply for a new one outside of the open enrollment period. You’ll need to submit proof of the qualifying life event with your application and apply within 60 days of your qualifying life event.

Avoid Medicare Part D Penalties

Suppose you move from a Medicare Advantage Plan that includes prescription drug coverage to a stand-alone Medicare Prescription Drug Plan . In that case, youll be returned to Original Medicare.

Suppose you disenroll in a Medicare Advantage Prescription Drug Plan and lose your creditable prescription drug coverage. In that case, you may have to wait until your next enrollment opportunity to get drug coverage. This may cause you to pay a Part D late enrollment penalty.

Involuntary Loss Of Other Coverage

The coverage youre losing has to be minimum essential coverage, and the loss has to be involuntary. Canceling the plan or failing to pay the premiums does not count as involuntary loss, but voluntarily leaving a job and thus losing employer-sponsored health coverage does count as an involuntary loss of coverage. In most cases, loss of coverage that isnt minimum essential coverage does not trigger a special open enrollment.

. And although they are not technically considered minimum essential coverage, they do count as minimum essential prior coverage in the case of special enrollment periods that require a person to have previously had coverage .)

As noted above, loss of coverage is the most common qualifying event, and applicants will continue to have to provide proof of loss of coverage when they seek a special enrollment period for this.

Your special open enrollment begins 60 days before the termination date, so its possible to get a new ACA-compliant plan with no gap in coverage, as long as your prior plan doesnt end mid-month. the code of federal regulations 155.420, and the that makes advance open enrollment possible for people with individual coverage as well as employer-sponsored coverage.) You also have 60 days after your plan ends during which you can select a new ACA-compliant plan.

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What Is A Qualifying Life Event

Under the Patient Protection and Affordable Care Act, most people are required to get their insurance during the Open Enrollment Period, which typically comes at the end of each year. If you have a qualifying life event, you may be eligible for a special enrollment period outside of the ordinary OEP. & amp amp lt span data-mce-type=bookmark style=display: inline-block width: 0px overflow: hidden line-height: 0 class=mce_SELRES_start& amp gt & amp amp lt /span& amp gt

Circumstances that could pertain to qualifying life events and your eligibility to pursue a 60-day special enrollment period include

Learn More About Medicare Enrollment

How a Special Enrollment Period Works

1 Every year, Medicare evaluates plans based on a 5-star rating system.

MedicareAdvantage.com is a website owned and operated by TZ Insurance Solutions LLC. TZ Insurance Solutions LLC and TruBridge, Inc. represent Medicare Advantage Organizations and Prescription Drug Plans having Medicare contracts enrollment in any plan depends upon contract renewal.

Plan availability varies by region and state. For a complete list of available plans, please contact 1-800-MEDICARE , 24 hours a day/7 days a week or consult www.medicare.gov.

Medicare has neither reviewed nor endorsed this information.

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What Are Special Enrollment Periods

The Affordable Healthcare Act limits when employees can make changes to their health insurance plans. A special enrollment period is the time window allotted to an employee to make needed changes to their insurance outside of the annual Open Enrollment period .

Special enrollment periods are triggered only by qualifying life events. These are defined as a change in life circumstances that make a change to health insurance appropriate right then. Examples include having a baby or a child leaving home and getting their own insurance.

Under employer-sponsored health plans, employees generally have at least 30 days after a qualifying life event when the special enrollment period is triggered. Specific exceptions may apply based on the employer. In the Federal Marketplace on HealthCare.gov, qualified individuals are given 60 days of special enrollment period.

It is always important to study the Summary Plan Descriptions and other plan documents from your insurance carrier to understand both the allotted special enrollment periods specific to your companys plans and also what are considered qualifying life events.

Special Enrollment Period Based On Qualifying Life Event

Did you know that you can sign up for health coverage within 60 days of experiencing a Qualifying Life Event ? Dont delay get a quick quote today and see what financial help you may qualify for!

In most cases, you have sixty days following your life event to enroll in coverage. For instance, if you moved to Rhode Island on April 1, 2022, you would have until May 30, 2022 to enroll in coverage. Remember: health coverage is required in the state of Rhode Island. Remember to get covered and stay covered all throughout the year to avoid a penalty when filing your tax returns.

PLEASE NOTE: The options listed below are not all the life events that may qualify you to enroll in coverage through our SEP. Call us at 1-855-840-4774 to see if you qualify.

If you have questions about coverage through HealthSource RI, or need help enrolling in coverage, there is more than one way to connect to support. You can:

  • Attend one of our virtual Info Sessions and learn more about HealthSource RI, including how to enroll and what financial help you may be eligible for. For a full calendar of our events, .
  • Make an appointment with a Navigator for 1-on-1 virtual enrollment support. to reserve your appointment in advance.
  • Use our live web chat . Simply click on the blue Chat with us bubble in the bottom-right anywhere on our website.

Starting February 1, 2022, HSRI offers a Special Enrollment Period for any individual experiencing a Qualifying Life Event . A QLE can include:

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Life Changes That Can Qualify You For A Special Enrollment Period

Important: If you had a change more than 60 days ago but since January 1, 2020

If you qualified for a Special Enrollment Period but missed your deadline to enroll in coverage because you were impacted by the COVID-19 emergency, you may be eligible for a Special Enrollment Period.

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, you may qualify for this Special Enrollment Period through the application.

If you had a life event other than a loss of coverage more than 60 days ago and missed your Special Enrollment Period, contact the Marketplace Call Center at 1-800-318-2596 for more information.

New Special Enrollment Period Changes

You still have time to enroll in a healthcare plan: Part 2

New changes to the special enrollment period, grant year-round enrollment in ACA-compliant health insurance to some applicants if household income does not exceed 150% of the federal poverty level . Coverage will take effect the first of the following month.

There are no restrictions on how often this special enrollment period can be used or the type of health plan that can be chosen. A person with an eligible household income who is already enrolled in an exchange plan can utilize this SEP to switch plans, albeit the deductible and out-of-pocket expenditure for the year will be reset to $0 when the new plan begins.

Federal Poverty Level Adjusted to 150%

In Florida, 150 percent of the poverty threshold equates to an annual salary of no more than $19,320 for a single person enrolling in coverage for 2022.

  • $19,320 for individuals
  • $26,130 for a family of 2
  • $32,940 for a family of 3
  • $39,750 for a family of 4
  • $46,560 for a family of 5
  • $53,370 for a family of 6
  • $60,180 for a family of 7
  • $66,990 for a family of 8

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Need Coverage At The End Of The Year

If you find yourself without health insurance towards the end of the year, you might want to consider a short-term policy instead of an ACA-compliant policy . There are pros and cons to short-term insurance, and its not the right choice for everyone. But for some, its an affordable solution to a temporary problem.

Short-term insurance doesnt cover pre-existing conditions, so its really only an appropriate solution for healthy applicants. And for applicants who qualify for premium subsidies in the exchange, an ACA-compliant plan is also likely to be the best value, since there are no subsidies available to offset the cost of short-term insurance.

But if youre healthy, dont qualify for premium subsidies, and you find yourself without coverage for a month or two at the end of the year, a short-term plan is worth considering. You can enroll in a short-term plan for the remainder of the year, and sign up for ACA-compliant coverage during open enrollment with an effective date of January 1.

The temporary health plan would certainly be better than going without coverage for the last several weeks of the year, and it would be considerably less expensive than an ACA-compliant plan for people who dont get premium subsidies.

For Health Plans Through Work

If you want to add or change health insurance through an employer, check with your employer about its health plans options. Similar to the ACA marketplace, youll need to provide proof of your qualifying life event. Once you give that information, you should be able to choose among the plans offered to employees.

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What Qualifies You For A Special Enrollment Period

A Medicare Special Enrollment Period allows you to switch plans or sign up for a Medicare plan outside your standard Medicare enrollment periods. Including outside of the Annual Enrollment Period that occurs October 15th December 7th annually.

There are three primary reasons why you may qualify for a Special Enrollment Period:

The Centers for Medicare and Medicaid Services rates Medicare plans on a scale of 1 to 5 stars, with 5-stars being excellent. Is a Medicare Advantage, Medicare drug plan, or Medicare Cost Plan with a 5-star rating available in your area? If so, you can use the 5-star Special Enrollment Period to switch from your current plan to a 5-star quality rating plan.

Did you delay Medicare enrollment because you had creditable coverage through an employer or other source? Then you may have an 8-month Special Enrollment Period for enrolling in Original Medicare , and expanded Medicare coverage, once you lose creditable coverage.

Find the right Medicare plan for you

Other Ways To Trigger A Special Enrollment Period

Special Enrollment Periods Give You Coverage After a Life Change ...

A qualifying life event isn’t the only way to qualify for a special enrollment period. Other circumstances that can allow you to make changes to your health coverage include experiencing an enrollment or policy information display error, gaining or becoming a dependent due to child support, or getting an appeal decision that’s in your favor.

You’ll also qualify if you gain membership in a federally recognized tribe, become an Alaska Native Claims Settlement Act Corporation shareholder, or begin or end service with AmeriCorps State, AmeriCorps National, VISTA, or NCCC.

You may also qualify for a special enrollment period if you previously qualified in the previous 60 days but missed your deadline to enroll in health plan coverage due to the COVID-19 Public Health Emergency.

In September 2021, the U.S. Department of Health & Human Services established a new special enrollment period for households with income of less than 150% of the federal poverty level , as long as the applicant is also eligible for premium tax credits that cover the cost of a benchmark plan. In 2022, 150% of the FPL corresponds to $19,320 for a single person.

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*new For 2022* Special Enrollment Period Based On Household Income

Due to changes at the federal level, eligible Rhode Islanders who meet certain income and household requirements may now be eligible to enroll in coverage through HealthSource RIs Special Enrollment Period. This is available starting February 2022 until December 31, 2022.

Even if you have not experienced a Qualifying Life Event , you may still be eligible to enroll in coverage if you meet all of the following conditions:

  • You are eligible to enroll in coverage through HealthSource RI,
  • You qualify to receive financial assistance/ Advanced Tax Premium Credits to help lower your coverage costs, and
  • Your household income does not exceed 150% of the Federal Poverty Level. Please refer to the table below:

If you or someone in your household meets all of these conditions, we can connect you to health coverage with financial help. Please note: your coverage will begin on the 1st of the month following your complete enrollment.

Loss Of Health Insurance

You may qualify for a Special Enrollment Period 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.

Important: If you lost coverage more than 60 days ago, but since January 1, 2020, and didnt enroll sooner because you were impacted by the COVID-19 emergency declared by FEMA, you may still qualify for a Special Enrollment Period.

Coverage losses that may qualify you for a Special Enrollment Period:

Losing job-based coverage

You may qualify for a Special Enrollment Period if you lose health coverage through your employer or the employer of a family member, including if you lose health coverage through a parent or guardian because you’re no longer a dependent.

Important: Voluntarily dropping coverage you have as a dependent doesn’t qualify you for a Special Enrollment Period unless you also had a decrease in household income or a change in your previous coverage that made you eligible for savings on a Marketplace plan.
Losing eligibility for Medicaid or CHIP

You may qualify for a Special Enrollment Period if you lose Medicaid or Childrens Health Insurance Program coverage because:

  • You lose your eligibility. For example, you may have a change in household income that makes you ineligible for Medicaid, or you may become ineligible for pregnancy-related or medically needy Medicaid.
  • Your child ages off CHIP.

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What Do I Do If I Qualify For A Special Enrollment Period

If you’ve experienced one of the qualifying events listed above, you’re ready to apply for a special enrollment period. You can do this either through Healthcare.gov1 or your state exchange2.

Your application will be different depending on whether you’ve experienced a qualifying life event or if you’ve 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 questions3 to see if you qualify for a special enrollment period.

If you have a special circumstance rather than a qualifying life event, you’ll want to contact the marketplace 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 a special enrollment period.

Special Enrollment Period Qualifying Life Events

How To Qualify for SEP (Special Enrollment Period) ACA Health Insurance Plans.

There are several life events that qualify for a special enrollment.

Qualifying events may include:

  • You lose other health coverage due to job loss, a decrease in work hours, or end of COBRA coverage.
  • Your current health care coverage is ending on a date other than December 31st of the current plan year.
  • You move to a new area that provides you different plans or isnt covered by your current insurance network.
  • You get married.
  • You give birth to or adopt a child, or gain a dependent through a court-order.
  • You obtain U.S. citizenship.
  • Your income or household status changes.
  • You are no longer covered on a parents policy because you turned 26.
  • You have legally separated from or divorced your spouse.
  • The primary policyholder on your current health insurance passed away.
  • You were affected by a FEMA-declared emergency or major disaster.

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Who Doesnt Need A Qualifying Event

In some circumstances, enrollment is available year-round, without a need for a qualifying event:

  • Medicaid and CHIP enrollment are also year-round. For people who are near the threshold where Medicaid eligibility ends and exchange subsidy eligibility begins, there may be some churning during the year, when slight income fluctuations result in a change in eligibility.If income increases above the Medicaid eligibility threshold, theres a special open enrollment window triggered by loss of other coverage. Unfortunately, in states that have not expanded Medicaid, the transition between Medicaid and QHPs in the exchange is nowhere near as seamless as lawmakers intended it to be.
  • And in addition to Medicaid/CHIP, some states have other types of coverage that can be obtained outside of open enrollment:
  • Basic Health Programs in New York and Minnesota .
  • The ConnectorCare program in Massachusetts .
  • Employers can select SHOP plans year-round. But employees on those plans will have the same sort of annual open enrollment windows that applies to any employer group plans.

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