Special Enrollment Periods: Are you eligible?

Enrolling in an ACA health plan isn’t possible for much of the year — unless you’re eligible for an SEP. Here’s what you need to know about them.

The deadline to enroll in Affordable Care Act (ACA) marketplace health insurance plans ended in most states all the way back on January 15. (The ACA marketplace is a government-run website where you can buy health insurance.)

But if you missed the cutoff point, you’re not necessarily out of luck. In fact, you may still be able to enroll in a plan if you qualify for a Special Enrollment Period (SEP). (If you’re a Native American or an Alaskan Native member of a federally recognized tribe, this doesn’t apply to you — you can sign up for marketplace coverage anytime.)

“SEPs occur when there’s a life event where your situation dramatically changes,” says David Anderson, research associate at the Duke-Margolis Center for Health Policy and an adjunct professor at the Sanford School of Public Policy at Duke University.

So how do you qualify for an SEP? In general, you need to:

Have had a qualifying life event
Have proof that it took place as you say it did
Apply for insurance within 60 days of it happening (in some cases, you also have 60 days before the event to apply)

Below, find the five most important questions to ask about SEPs.

1. What counts as a qualifying life event?

In general, qualifying events occur if you lose your health coverage, your household size changes, you make a long-distance move, or you’re newly eligible for marketplace subsidies (discounts that come in the form of government tax credits).

Some common qualifying life events:

You lose your job (and your health insurance with it)
You get married (generally, at least one spouse needs to have had healthcare coverage before the wedding)
You get divorced or legally separated (and lose your coverage)
You have a baby or adopt a child
Someone on your health insurance policy dies
You move to a new home in an area where different health plans are available (as long as you had coverage before the move)
You turn 26 (the age at which you’re taken off your parents’ health plan)
You become a U.S. citizen

But other more complicated situations may also apply.

For example, you may qualify for an SEP if something outside of your control — say, a house fire, an illness, or a natural disaster — kept you from signing up during Open Enrollment. (Colorado, which has a state-run ACA marketplace, offered an SEP in response to the COVID-19 omicron surge and wildfires.)

Another rare but possible option: If a technical error kept you from being able to enroll, or if you were given the wrong information about the details of your plan — for example, the website incorrectly stated that a certain provider was in network — that counts too, says Caitlin Donovan, senior director of the National Patient Advocate Foundation.

(Pro tip: When signing up, always take screenshots of technical errors or other potential problems, as they may help your case if you need to apply for an SEP, Donovan says.)

Yet another situation that counts: if you applied for Medicaid or the Children’s Health Insurance Program (CHIP) during Open Enrollment and found out that you were ineligible after Open Enrollment ended. (Medicaid and CHIP are types of healthcare coverage offered to people with a low yearly income.)

Of course, the easiest way to know if you qualify for an SEP is to ask, Anderson says.

You can do so by contacting a licensed insurance agent at 1-800-273-8115 to walk you through your options.

2. Are there any new SEP rules for 2022?

The simple answer is yes. Starting this year, healthcare.gov is offering a new SEP if you earn less than 150% of the federal poverty level — that’s $20,385 per year for a single individual or $34,545 for a family of three. (Note that the poverty thresholds are higher in Alaska and Hawaii.)

If that’s you, you can enroll in the marketplace anytime, Anderson says. Simply “attest” — or promise you’re telling the truth — to having 2022 income at or below 150% of the poverty level, then continue with your application.

You might be asked to provide proof if your 2022 income is a lot lower than the amount reported on your most recent federal income tax return (lower by 50% or $12,000, whichever is greater).

3. Now that I know what an SEP is, how do I apply for it?

A good place to start is by contacting a licensed insurance agent at 1-800-273-8115 for more information.

It can’t hurt to be prepared with documents proving your life event — your marriage license, for example, or your child’s adoption certificate — although if you don’t have them right away (or you’re not sure what you need), that’s all right, Anderson says. The licensed insurance agent you connect with can help you find out what documents you need.

Just make sure you submit those documents within 30 days of applying for coverage or your plan selection may be canceled. In some cases, you may not need any documentation. You’ll just need to attest that the information is true, with no evidence required.

It’s good to remember when your coverage starts, Donovan says. It may not take effect right away, so anticipate potential gaps in coverage, or try not to let your coverage lapse.

If you enroll in coverage via the marriage SEP, coverage starts on the first day of the following month. For a new baby or adopted child, coverage usually takes effect retroactively, going back to the date of birth or adoption.

Ready to explore insurance plans where you live?

4. Are there any exceptions to these rules?

Yes. In many cases, you can change health plans, but you may not be able to go from being uninsured to insured right away.

Also, if you already have marketplace coverage, don’t expect to change to whatever plan you want.

In fact, you may not be able to change plans at all: If you get married, you can add your new spouse to your current plan, or they can enroll in a separate one. But you can’t change plans. If you had a baby or adopted a child, you can add your new dependent (child) to your plan — but again, you can’t change plans (unless the plan you’re on doesn’t cover dependents).

If you can change plans, chances are you’ll have to choose from certain metal categories (that’s how the different ACA marketplace plans are presented: bronze, silver, gold, and platinum). In fact, the most common SEPs — loss of health insurance, moving to a new area, and a change in household size — allow you to pick a plan only from your current category.

A few instances when you can change categories:

You become newly eligible for cost-sharing reductions. These are special savings on deductibles (the amount you have to pay for health services before your health insurance kicks in), as well as copays and coinsurance (payments made after your deductible is met) that you have to be in a silver plan to take advantage of.
Your household size changes — due to marriage, birth, or adoption — and no other plans in your current category allow you to add new members. (In that case, you can enroll together in a category that’s one level up or one level down.)
You enrolled in the wrong plan due to misrepresentation or plan display error.

5. What if I don’t qualify for an SEP?

If you’re between Open Enrollment Periods and don’t qualify for an SEP, you may still have options. You can apply for Medicaid and CHIP year-round, if you qualify. (Find these plans in your state here.)

Another option is short-term, limited duration insurance. It’s a type of health insurance that offers coverage for a limited time, typically for several months to a year, and it can be a decent option for those who are relatively healthy and just need something to help them get by for a few months, says Anderson.

Just be sure you do your homework: Many short-term health plans have significant exclusions, such as pregnancy or labor delivery coverage, mental health services, and certain medications, which may not be immediately obvious. “Be very clear as to exactly what is covered,” Anderson says.

Plus, short-term health plans are generally subject to medical underwriting. If you have a preexisting condition, a short-term plan won’t cover expenses related to that condition, and you may not be able to qualify for coverage in the first place. “Most of these plans are designed for people who are relatively healthy, with a low probability of using many services,” Anderson says. Even if that’s you, you don’t want to rely on it as a long-term solution.

“Trying to put together short-term coverage for years at a time is risky,” Anderson says. “It’s what’s known as ‘reclassification risk,’ which is when something happens that transforms you from being healthy to not healthy, then all of a sudden your insurance disappears, or they charge you four times as much.”

With a marketplace plan, your premium won’t go up because of your health status, Anderson says.

Depending on what state you live in, you might also consider TriTerm Medical insurance — a “short-term” insurance that actually lasts for nearly three years.

Interested in exploring short term, TriTerm Medical, or other insurance plans? Learn more here.

This policy has exclusions, limitations, reduction of benefits and terms under which the policy may be continued in force or discontinued. For costs and complete details of the coverage, call [or write] your insurance agent or the company [whichever is applicable].

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Sources:

Healthcare.gov. "Enroll in or change 2022 plans — only with a Special Enrollment Period." Retrieved from https://www.healthcare.gov/coverage-outside-open-enrollment/special-enrollment-period/. Accessed March 1, 2022.

Healthcare.gov. "Federal Poverty Level (FPL)." Retrieved from https://www.healthcare.gov/glossary/federal-poverty-level-fpl/. Accessed March 1, 2022.

Healthcare.gov. "Guide to Confirming Your Income Information." Retrieved from https://marketplace.cms.gov/outreach-and-education/household-income-data-matching-issues.pdf. Accessed March 1, 2022.

Healthcare.gov. "Health coverage for American Indians & Alaska Natives." Retrieved from https://www.healthcare.gov/american-indians-alaska-natives/coverage/. Accessed April 22, 2022.

Healthcare.gov. "Special Enrollment Periods for complex issues." Retrieved from https://www.healthcare.gov/sep-list/. Accessed March 1, 2022.

Marketplace.cms.gov. "Understanding Special Enrollment Periods." Retrieved from https://marketplace.cms.gov/outreach-and-education/special-enrollment-periods-available-to-consumers.pdf. Accessed January 26, 2022.