In the United States, your ability to enroll for a health insurance plan depends largely on the date. Starting in October and continuing through the end of the year, the enrollment window opens, allowing people to tweak their current coverage or sign up for something entirely new. Outside of that window, if health insurance changes are necessary, the only way to lawfully make coverage alterations is to see if you qualify for a Special Enrollment Period, or SEP.
What’s a Special Enrollment Period (SEP)?
A special enrollment period is a small window outside of the annual open enrollment period (OEP) where people can get health insurance. When the Affordable Care Act was initially put in place, the rules surrounding how a person qualified for an SEP were less set in stone. Citizens could call Healthcare.gov and plead their case to a representative to order to get a special enrollment period. Now that the marketplace is older, qualifying events have become stricter. Here are a few examples of what could get you an SEP today…
- A change in marital status. Marriage, legal separation, and divorce count as changes.
- A change in household size. If someone in your home passes away, a baby is born, a child is adopted, or a child is put up for adoption, then you may qualify.
- A change of location. Moving your permanent location to a new county or state will open you up to different health plan options, so an SEP will be applied.
If you’d like more information on what qualifies someone for an SEP, read Healthcare.gov’s SEP information page.
Proof of Change
When you apply for a SEP, the federal government will ask you for proof regarding your qualifying event. So, for example, if a baby is added to your household, you will need to submit a verified copy of the child’s birth certificate to a representative for verification. Photos of the birth certificate would not be accepted.
Another more complex example would be if you moved. People no longer automatically qualify for a special enrollment period if they move; instead, the government requires that proof be shown that coverage was lost because of the move. This is where it gets tricky. Imagine a family of four–father, mother, and two children. The father is self-employed and doesn’t have health insurance, but the mother is offered insurance through her work. She and the two children are signed up for health insurance. Now, let’s say that the family moves from California to Virgina. When they arrived in their new home, only the mother and kids would qualify for a SEP because they’re the only ones who had health insurance prior to the move. The father would have to wait for the open enrollment period or consider purchasing unqualified health coverage for himself.
The point here is this: even if you qualify, you have a way to prove it before the federal government will open an enrollment window.
60-Day Window
Something that more Americans need to be aware of–on top of the rules and regulations that accompany getting an SEP–is that SEPs have a 60-day time limit from the day the event occurs before it closes again. It’s very important for anyone experiencing significant household changes to be proactive and prepared so that the chance isn’t lost.
For example, if a person loses their job and their group health insurance, they would qualify for an SEP. But in order to use their SEP, they will need to be on top of their inboxes and mailboxes for a letter from their old insurance carrier notifying them of their loss of coverage. The person will then have to submit that carrier letter to the federal government as quickly as possible so that it can be reviewed and the SEP window opened. The person will lose days to make changes starting from the minute they become officially unemployed.
If going back and forth between the government, carriers, and other relevant parties takes too long, they’ll miss the sixty-day window from the time that the event occurred, and they’ll be out of luck.
All that said, if you miss your SEP, don’t panic. There are other options out there that can cover you in the interstice, such as short-term medical plans or fixed indemnity products. For more details on special enrollment periods, please watch the video posted below where Jeff Hess, Empower’s Individual Health specialist, discusses.
Have Health Insurance Questions?
We hope this information on special enrollment periods has been helpful!
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Updated on 11/1/24.