See If You May Qualify for a Special Enrollment Period for Health Insurance Outside of Open Enrollment : Catherine Giles, An Independent Insurance Agent, Blog
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Catherine Giles, Independent Insurance Agent

See If You May Qualify for a Special Enrollment Period for Health Insurance Outside of Open Enrollment

by Catherine Giles on 02/24/17

See If You May Qualify for a Special Enrollment Period for Health Insurance

Contact Independent Insurance Agent Catherine Giles at 940-597-4757 or [email protected] to see if you may qualify for a Special Enrollment Period for Health Insurance outside of Open Enrollment

Life changes that can qualify you for a Special Enrollment Period, as listed from the Marketplace.

Loss of health insurance

You may qualify for a Special Enrollment Period if you or anyone in your household lost qualifying health coverage in the past 60 days OR expects to lose coverage in the next 60 days.

Coverage losses that may qualify you for a Special Enrollment Period:

Losing job-based coverage

You may qualify for a Special Enrollment Period if you lose health coverage through your employer or the employer of a family member, including if:

· Your employer stops offering coverage.

· You leave a job where you had health coverage (even if you left your job by choice or were fired).

· You have a reduction in work hours that causes you to lose your job-based plan.

· Your job-based plan doesn’t offer qualifying health coverage and as a result you become newly eligible for a premium tax credit. Most job-based plans count as qualifying health coverage. To find out if your employer’s coverage meets the standards, ask your employer to complete the Employer Coverage Tool (PDF).

· Your job-based health plan is ending for the year and you choose not to renew it. Note: If the plan is affordable and meets minimum value standards, you can buy Marketplace insurance but won’t qualify for a premium tax credit or other savings.

· Your former employer stops contributing to your retirement coverage, requiring you to pay full cost.

Note: You DON’T qualify for a Special Enrollment Period if:

· You voluntarily drop your job-based coverage during your coverage year while still working for your employer.

· You lose your job-based coverage because you didn’t pay your premium.

Losing COBRA coverage

Some special rules apply if you’re losing COBRA continuation coverage.

You DO qualify for a Special Enrollment Period if:

· Your COBRA coverage runs out.

· Your former employer stops contributing to your COBRA coverage, requiring you to pay the full cost.

You DON’T qualify for a Special Enrollment Period if:

· You decide to end COBRA early (and are paying the full cost yourself).

· You lose your COBRA coverage because you didn’t pay your premiums.

Note: You don’t need a Special Enrollment Period if you voluntarily end COBRA early during a Marketplace Open Enrollment Period. You can drop your COBRA plan and enroll in a Marketplace plan at that time.

Losing individual health coverage for a plan or policy you bought yourself

You may qualify for a Special Enrollment Period if you lose individual health coverage, including if:

· Your individual plan or your Marketplace plan is discontinued (no longer exists).

· You lose eligibility for a student health plan.

· You lose eligibility for a plan because you no longer live in the plan’s service area.

· Your individual or group health plan coverage year is ending in the middle of the calendar year and you choose not to renew it.

Important: Losing individual coverage doesn’t qualify for a Special Enrollment Period if you voluntarily drop coverage, if you lose coverage because you didn’t pay your premiums, or if you lose Marketplace coverage because you didn’t provide required documentation when the Marketplace asked for more information.

Losing eligibility for Medicaid or CHIP

You may qualify for a Special Enrollment Period if you lose Medicaid or the Children’s Health Insurance Program (CHIP) because:

· You lose your eligibility. For example, you may have a change in household income that makes you ineligible for Medicaid, or you may become ineligible for pregnancy-related or medically needy Medicaid.

· Your child ages off CHIP.

Losing eligibility for Medicare

You may qualify for a Special Enrollment Period if you become no longer eligible for premium-free Medicare Part A.

You don’t qualify for a Special Enrollment Period if:

· You lose Medicare Part A because you didn’t pay your Medicare premium.

· You lose Medicare Parts B, C, or D only.

Losing coverage through a family member

You may qualify for a Special Enrollment Period if you lose qualifying health coverage you had through a parent, spouse, or other family member. This might happen if:

· You turn 26 (or the maximum dependent age allowed in your state) and can no longer be on a parent’s health plan.

· You lose job-based health coverage through a family member’s employer because that family member loses health coverage or coverage for dependents.

· You lose health coverage through a spouse due to a divorce or legal separation.

· You lose health coverage due to the death of a family member.

· You lose health coverage through a parent or guardian because you’re no longer a dependent.

Important: Losing coverage you have as a dependent doesn’t qualify for a Special Enrollment Period if you voluntarily drop the coverage. You also don’t qualify if you or your family member lose coverage because you don’t pay your premium.

Changes in household size

You may qualify for a Special Enrollment Period if you or anyone in your household in the past 60 days:

· Got married. Pick a plan by the last day of the month and your coverage can start the first day of the next month.

· Had a baby, adopted a child, or placed a child for foster care. Your coverage can start the day of the event — even if you enroll in the plan up to 60 days afterward, and even if the event happened late in 2016.

o Example: You had a baby December 17, 2016 and enroll in a 2016 plan February 8, 2017. The coverage applies to medical services from December 17 through December 31, 2016. Your 2017 plan would cover your expenses from January 1, 2017 on. Note: If the event happened in 2016, contact me to enroll in 2016 coverage.

· Got divorced or legally separated and lost health insurance. Note: Divorce or legal separation without losing coverage doesn’t qualify you for a Special Enrollment Period.

· Death. You’ll be eligible for a Special Enrollment Period if someone on your Marketplace plan dies and as a result you’re no longer eligible for your current health plan.

Changes in residence

Household moves that qualify you for a Special Enrollment Period:

· Moving to a new home in a new ZIP code or county

· Moving to the U.S. from a foreign country or United States territory

· A student moving to or from the place they attend school

· A seasonal worker moving to or from the place they both live and work

· Moving to or from a shelter or other transitional housing

Note: Moving only for medical treatment or staying somewhere for vacation doesn’t qualify you for an SEP.

Important: You must prove you had qualifying health coverage for one or more days during the 60 days before your move. You don’t need to provide proof if you’re moving from a foreign country or United States territory.

More qualifying changes

Other life circumstances that may qualify you for a Special Enrollment Period:

· Changes that make you no longer eligible for Medicaid or the Children’s Health Insurance Program (CHIP)

· Gaining membership in a federally recognized tribe or status as an Alaska Native Claims Settlement Act (ANCSA) Corporation shareholder

· Becoming newly eligible for Marketplace coverage because you became a U.S. citizen

· Leaving incarceration

· AmeriCorps VISTA members starting or ending their service

· Other complicated cases that may qualify you for a Special Enrollment Period

Special Enrollment Periods for complex issues

Outside the Open Enrollment Period, you can enroll in a private health plan through the Marketplace only if you qualify for a Special Enrollment Period.

You can qualify for a Special Enrollment Period if either of the following applies to you:

You have a qualifying life event like having a baby, getting married, or losing minimal essential coverage. Learn more about Special Enrollment Periods and other coverage options outside Open Enrollment.

You have other complicated situations, as described on this page.

Below are cases and examples that may also qualify you for a Special Enrollment Period:

Exceptional circumstance

You faced a serious medical condition or natural disaster that kept you from enrolling. For example:

· An unexpected hospitalization or temporary cognitive disability, or were otherwise incapacitated

· A natural disaster, such as an earthquake, massive flooding, or hurricane

Enrollment or plan information display errors

· Misinformation, misrepresentation, misconduct, or inaction of someone working in an official capacity to help you enroll (like an insurance company, navigator, certified application counselor, or agent or broker) kept you from:

o Enrolling in a plan

o Enrolling in the right plan

o Getting the premium tax credit or cost-sharing reduction you were eligible for

· A technical error occurred when you applied on HealthCare.gov -- you probably saw an error message when completing your application – that prevented:

o You from enrolling in a plan, or

o Your health insurance company from receiving your enrollment information

· The wrong plan data was displayed on HealthCare.gov at the time that you selected your health plan, such as benefit or cost-sharing information.

Previously lived in a state that hasn’t expanded Medicaid and you become newly eligible for help paying for a Marketplace insurance plan because of an increase in household income or move

You previously lived in a state that hasn’t expanded Medicaid and weren’t eligible for Medicaid or advance payments of the premium tax credit (APTC) because your income was too low. But in the last 60 days, you had an increase in household income or moved, making you newly eligible for premium tax credits.

Being determined ineligible for Medicaid or CHIP

You applied for Medicaid or CHIP during the Marketplace Open Enrollment Period and your state Medicaid or CHIP agency determined that you weren’t eligible for Medicaid or CHIP after Open Enrollment ended. You may qualify for a Special Enrollment Period regardless of whether you applied through:

· The Marketplace and your information was sent to your state Medicaid or CHIP agency, or

· Your state Medicaid or CHIP agency directly

Gain or become a dependent due to a child support or other court order

You gained a new dependent or became a dependent of someone else due to a court order. Your coverage would start the effective date of the court order – even if you enroll in the plan up to 60 days afterward.

Experience domestic abuse/violence or spousal abandonment

You're a survivor of domestic abuse/violence or spousal abandonment and want to enroll in your own health plan separate from your abuser or abandoner. You can enroll by contacting the Marketplace Call Center. Your dependents may be eligible too.

If you’re married to your abuser/abandoner, you can answer on your Marketplace application that you’re unmarried, without fear of penalty for mis-stating your marital status. You then become eligible for a premium tax credit and other savings on a Marketplace plan, if you qualify based on your income.

If you qualify for this SEP, you'll have 60 days to enroll in a Marketplace plan.

Prevail on Appeal

You believe you received an incorrect eligibility determination or an incorrect coverage effective date and file an appeal with the Marketplace. If the ruling goes in your favor, you’ll be given the option to enroll in or change plans either retroactively or prospectively.

If you think you qualify for a Special Enrollment Period

If you think you qualify for a Special Enrollment Period for one of the situations listed on this page, contact me at 940-5974757.

If you’re already enrolled in a plan and you get a Special Enrollment Period, you can stay in your current plan in most cases, or you can switch plans. In some limited cases, you may qualify for an earlier effective date of coverage. Remember, you must make the first premium payment before your coverage becomes effective.

Filing an appeal

If your request for a Special Enrollment Period is denied, you can file an appeal. If the denial is found incorrect, you can get coverage back to the date your Special Enrollment Period was denied.

How to file an appeal:

· Select your state’s appeal form, download it, and fill it out

· Mail your appeal to:

Health Insurance Marketplace

Attn: Appeals

465 Industrial Blvd.

London, KY 40750-0061

When possible, include a copy of any eligibility determination notice or other official notice you received. This isn’t required, but will help us process your appeal.

When mailing the appeal request to the Health Insurance Marketplace, be sure to include the last 4 digits of the London, KY ZIP code (40750-0061). This will help your appeal arrive faster.

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