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A Common List of Qualifying Events Triggering a Special Enrollment Period (SEP)

by | Feb 10, 2022 | ACA Enrollment, American Exchange News, Enrollment

With the Open Enrollment period having come to an end, it’s important to be aware of the ways you can receive healthcare coverage outside of the traditional enrollment window. What you need is a qualifying event, which is a specific circumstance that has changed your life, triggering a Special Enrollment Period (SEP) for you.  

There are several Qualifying events that will allow you to enroll into a plan but let us review the most common. 

  1. Involuntary loss of coverage 
  1. Becoming a dependent or gaining a dependent 
  1. Marriage / Divorce 
  1. Change in primary place of living 
  1. An error or problem with enrollment 
  1. Employer-sponsored plan becomes unaffordable or stops providing minimum value 
  1. An income or circumstance change that makes you newly eligible (or ineligible) for subsidies  

Involuntary loss of coverage 

The coverage you’re losing has to be minimum essential coverage, and the loss has to be involuntary. Cancelling 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. Other examples include: 

  • Coverage through a job, or through another person’s job. This also applies if you’re now eligible for help paying for Marketplace coverage because your employer stopped offering coverage or the coverage is no longer considered qualifying coverage, and you’re allowed to end employer coverage.  
  • Medicaid or Children’s Health Insurance Program (CHIP) coverage (including pregnancy-related coverage and medically needy coverage).  
  • Medicare.  
  • Individual health coverage that ended after a decrease in household income that makes someone newly eligible for savings on a Marketplace plan.  
  • Individual or group health plan coverage that ends during the year.  
  • Coverage under your parent’s health plan (if you’re on it). If you turn 26 and lose coverage, you can qualify for this Special Enrollment Period. 

Becoming a dependent or gaining a dependent 

This can also be considered a change in your household size, which includes:  

  • Got married  
  • Had a baby, adopted a child, or placed a child for foster care 
  • Gained or became a dependent due to a child support or other court order 

Marriage or divorce 

If you get married, you have a 60-day open enrollment window that begins on your wedding day. However, at least one partner must have had minimum essential coverage  for at least one of the 60 days prior to the marriage. In other words, you cannot use marriage to gain coverage if neither of you had coverage before getting married. 

If you lose your existing health insurance because of a divorce, you qualify for a special open enrollment based on the loss of coverage rule above. 

Change in primary place of living 

This special enrollment period applies as long as you move to an area where different qualified health plans are available. 

  • 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  
  • Moving to or from the place you attend school  
  • Moving to or from the place of your seasonal employment  
  • Moving to or from a shelter or other transitional housing 

An error or problem with enrollment 

By chance, if there is an enrollment error at the fault of the exchange, HHS, or an enrollment assister, a special enrollment period can be granted. In this case, the exchange can properly enroll the person (or allow them to change plans) outside of open enrollment in order to remedy the problem. 

Employer-sponsored plan becomes unaffordable or stops providing minimum value 

An employer-sponsored plan is considered affordable in 2021 as long the employee isn’t required to pay more than 9.83% of household income for just the employee’s portion of the coverage.  

A plan design change could result in a plan no longer providing minimum value. And there are a variety of situations that could result in a plan no longer being affordable, including a reduction in work hours or an increase in the premiums that the employee must pay for their coverage. 

An income or circumstance change that makes you newly eligible (or ineligible) for subsidies 

If your income or circumstances change such that you become newly eligible or newly ineligible for premium tax credits or newly-eligible for cost-sharing subsidies, you’ll have an opportunity to switch plans. 

What if I think I qualify for a Special Enrollment Period? 

If you’re in need of healthcare care coverage and it’s outside of the of the Open Enrollment period, give American Exchange a call. Our licensed healthcare professionals have the proper resources available to identify any enrollment opportunities or qualifying events that may help you get covered today. 

Call American Exchange today at 888.995.1674 or email us at  rcm@americanexchange.com