If you want to buy health insurance outside of the annual Open Enrollment Period, you must qualify for a Special Enrollment Period (SEP). To qualify for special enrollment, you generally must have had a qualifying life event in the last 60 days or expect to have one in the next 60 days. Life events include getting married, having a baby, losing a job, moving, and more.
In this guide, we walk you through everything you could want to know about Special Enrollment Periods. (If you’re unfamiliar with the concept of enrollment periods, it might help you to read this article before continuing.)
Types of Special Enrollment Periods
In this section, we walk through the different types of Special Enrollment Periods and how they work. These include:
- Loss of “qualifying” health insurance coverage
- Change in household size
- Change in residence
- Change in household income
- Change in eligibility status
- New health reimbursement arrangement (HRA) offering by an employer
- Other complicated situations
Loss of “qualifying” health insurance coverage Special Enrollment Periods
You may qualify for a Special Enrollment Period if you or anyone in your household has lost qualifying health coverage in the past 60 days or expects to lose it in the next 60 days. Common situations include:
- Losing job-based coverage for any reason, including resigning, being laid off, or getting fired
- Losing coverage due to divorce or family changes (e.g. a death in the family)
- Policy/plan year ending for a plan or policy you bought yourself (e.g. a grandmothered non-calendar year plan)
- COBRA coverage running out or your former employer stopping contributing to your COBRA coverage
- Aging off a parent's plan by turning 26
- Losing eligibility for Medicaid or CHIP
(Examples of qualifying coverage include individual health insurance, job-based coverage, and government programs.)
If you voluntarily give up your coverage or lose it because you don’t pay your premium, the loss will not qualify you for a Special Enrollment Period.
Change in household size Special Enrollment Periods
You may qualify for a Special Enrollment Period if you experienced one of the following household events in the past 60 days:
- Got married
- Had a baby
- Added a dependent
Changes in your household size resulting from divorce, legal separation, or death do not qualify you for a Special Enrollment Period unless the change causes you to lose coverage.
Change in residence Special Enrollment Periods
You may qualify for a Special Enrollment Period if you experienced one of the following residential move events in the past 60 days:
- Moving to a new home in a new ZIP code or county
- Moving to the U.S. from a foreign country or U.S. territory
- If you're a student, moving to or from the place you attend school
- If you're a seasonal worker, moving to or from the place you both live and work
- Moving to or from a shelter or other transitional housing
Unless you’re moving from a foreign country or U.S. territory, you must have had qualifying health coverage for at least one of the 60 days prior to the move. Also, if you move temporarily for medical treatment or vacation, it doesn't qualify you for a Special Enrollment Period.
Change in household income Special Enrollment Periods
If you experience a change in income, you may be eligible for a Special Enrollment Period. Not all income changes qualify you for a Special Enrollment Period. The ones that do include changes in income that:
- Make you newly eligible for premium tax credits
- Make you newly eligible for cost-sharing reductions
- Make your employer-provided coverage unaffordable
Generally, you must have qualifying health coverage at the time of your income change to be eligible for this type of Special Enrollment Period.
Change in eligibility status Special Enrollment Periods
You may qualify for a Special Enrollment Period if you become newly eligible to enroll in Marketplace coverage. Examples of changes in eligibility status include:
- Being denied Medicaid/CHIP
- Gaining citizenship or lawful presence in the U.S.
- Being released from incarceration (detention, jail, or prison)
- Starting or ending service as an AmeriCorps State and National, VISTA, or NCCC member
New health reimbursement arrangement (HRA) offering by an employer Special Enrollment Periods
You may be eligible for a Special Enrollment Period if you or anyone in your household gained access to a qualifying HRA in the last 60 days or expects to gain access to one in the next 60 days. HRAs are employer-provided benefit programs used to reimburse employees tax-free for their out-of-pocket health insurance premiums and medical expenses. Qualifying HRAs include:
- Individual Coverage HRAs (ICHRAs)
- Qualified Small Employer HRAs (QSEHRAs)
Other complicated situation Special Enrollment Periods
There are a number of additional unique circumstances that might qualify you for a Special Enrollment Period. (For detailed information on complex issues, see this list.) Some examples of complicated situations include:
- You experience an exceptional circumstance from a serious medical condition, natural disaster, or other national or state-level emergency that keeps you from enrolling
- You experience a Marketplace enrollment or plan information display error
- You gain or become a dependent due to a court order
- You experience domestic abuse/violence or spousal abandonment
- You get an appeal decision that’s in your favor
Documentation requirements for Special Enrollment Periods
When you apply, you must attest that the information you provide in your application is true. This includes the events that qualify you for a Special Enrollment Period. After you submit your application, you may be required to submit documents to confirm these events.
(Note: If you’re denied a Special Enrollment Period, you can appeal the decision by submitting an appeal form.)
Start dates for coverage purchased during Special Enrollment Periods
In general, the coverage you purchase during a Special Enrollment Period starts on the 1st of the following month. However, there are some exceptions for certain types of Special Enrollment Periods.
In special cases, your coverage may be retroactive. If your Special Enrollment Period was triggered by a new child added to your household, coverage starts on the child’s birth date or adoption date.
In other cases, your coverage won’t start until the first day of the second month after you purchase it. If your Special Enrollment Period is from a change in residence, you'll need to submit your application by the 15th for your coverage to start on the 1st of the following month. If you apply after the 15th, your plan will start on the 1st of the second following month.
If you’re interested in more detail on Special Enrollment Periods, here’s a handy chart and the actual regulations.
