Special Enrollment Periods

Under certain circumstances, individuals may enroll in a QHP or change QHPs outside of the annual open enrollment period. These SEPs are based on certain triggering events or special circumstances.

Events that permit an SEP include:

  • Gaining or becoming a dependent through marriage, birth, adoption, placement for adoption, or placement in foster care
  • Gaining status as a citizen, national, or lawfully present individual
  • Loss of coverage (e.g., loss of Medicaid eligibility, QHP no longer available), except if enrollment is terminated based on failure to pay premiums, fraud, or enrollee initiated termination
  • Determination that an individual is newly eligible or ineligible for advance payments of the premium tax credit or a change in eligibility for cost-sharing reductions
  • Permanent move to an area where different QHPs are available
  • American Indian or Alaskan Native status
  • Misconduct of a Navigator, consumer assister, agent or broker, or insurer customer service representative, or misconduct of a QHP while conducting direct enrollment
  • Errors, contract violations, or other exceptional circumstances identified by the Marketplace

Most SEPs extend for 60 days from the date of the triggering event. The Marketplace permits consumers to access the SEP for loss of coverage up to 60 days before the anticipated loss date.

In order to apply for an SEP, individuals use the same Marketplace application as for the open enrollment period.

Have more questions about special enrollment periods? Contact your affordable care act experts at Total Benefit Solutions Inc., (215)355-2121 or (800)924-6718.