Health Insurance Special Enrollment Periods and Qualifying Life Events
Did you miss buying health insurance during the yearly open enrollment period? You can still get coverage during a special enrollment period. To qualify for one, you need a “change in situation.” Here’s what that means and what you can do about it.
If you don’t get health insurance through your or your spouse’s job, your best chance to get it is during the yearly open enrollment period.
Open enrollment isn’t your only chance to get it, though. You can buy a plan outside of enrollment if a life event or issue makes you eligible for a special enrollment period.
But what is a qualifying life event or complicated issue in this case? And how do you prove you’ve gone through one?
You’ll find answers to both of those questions here. You’ll also find information about:
- Situations that aren’t considered qualifying life events
- How you can tell if you’re eligible for a special enrollment period
- What to do if you’re turned down for a special enrollment period but you think you should qualify
- How to file an appeal if your request for a special enrollment period is denied
- Your options if you missed open enrollment and you don’t qualify for a special enrollment period
Speaking of open enrollment, it runs from Nov. 1 through Dec. 15 this year. Coverage starts on Jan. 1.
So what life events make someone eligible for a special enrollment period (or SEP)?
Examples of Qualifying Life Events
If you want to buy health insurance outside the annual open enrollment period, you’ve got to qualify for a special enrollment period. For that to happen, you usually have to experience something called a qualifying life event.
That may sound daunting, but don’t worry. Most of these life changes or events are pretty common. Most of them fit into one of three categories, too:
- Changes in household. Getting married or divorced, or having or adopting a baby.
- Changes in residence. That includes moving to a different ZIP Code, county, or from a foreign country to the US
- Loss of health insurance. Examples include losing job-based or individual coverage, or becoming ineligible for Medicare, Medicaid, or CHIP.
Let’s go over each situation and how it relates to SEP.
Changes in household
According to healthcare.gov, you qualify for a special enrollment period if you (or someone in your household):
- Get married
- Become separated or divorced
- Have a baby
- Start fostering a child
Here’s all you need to know about each of these life-altering changes.
The government lets you reevaluate your health insurance situation after you get married. Makes sense, right? After all, you and your spouse may want to switch to a plan that’s appropriate for both of you.
Speaking of which, before you start shopping for a health plan that covers you and your life partner, take a hard look at:
- Both of your health and medical histories as well as your current and future needs
- Your budget
- Any plans the two of you may have for starting a family (having kids) down the road
Get divorced or legally separated
Yes, getting divorced or separated can qualify you for a special enrollment period.
There are a couple of catches this time around, though. First, you need to become legally separated. In other words, a verbal separation won’t cut it. Why? The government and insurance companies need paperwork showing you’re separated.
Second, you must lose your health coverage as a result of your relationship change to gain access to a special enrollment period. If you split with your partner and don’t lose your coverage, you won’t qualify. You’ll have to wait until the next open enrollment period to buy or switch to a new plan.
Have a baby
Here’s another situation where it’s vitally important that you consider your health and medical needs.
The good news in this instance is you don’t have to choose a new health plan right away. You can wait up to 60 days after your baby arrives to do it.
Coverage starts the day your baby is born whether you switch plans before then or within that 60-day window afterward.
Speaking of health insurance and having a baby, we’ve published several articles on the subject. A few examples:
- How to Choose the Best Health Insurance Plan for Your Pregnancy
- Alternative Birth Options and Health Insurance Coverage
- Doulas and Health Insurance
- Unexpected Pregnancy Costs and How Health Insurance Covers (or Doesn't Cover) Them
- What Does Health Insurance Cover After Pregnancy?
In terms of a qualifying life event, adopting is like having a baby.
In other words, if you adopt, you’ll be able to buy or switch to a new health plan up to 60 days after the event.
You don’t have to wait until it’s a done deal, by the way. If you’re planning to adopt, you can apply for health coverage (knowing you’ll qualify for an SEP) before it’s official.
Either way, coverage should start the day you bring your child home.
Start fostering a child
Becoming a foster parent makes you eligible for a special enrollment period for health insurance.
It’s treated the same as adopting or giving birth to a child. And that includes the part about waiting up to 60 days after you foster a child.
Death in the household
You also may be able to use an SEP to buy or switch health coverage if someone in your household dies. For you to qualify, though, the death must make you ineligible for your current or existing plan.
Changes in residence
Not all the life changes need to take place within your household. Some involve relocating your place of residence. In particular, you’ll become eligible for a special enrollment period if you move:
- To a different ZIP Code or county
- To the United States from a US territory or foreign country
- To or from the place you go to school (you must be a student in this situation)
- To or from the place you live and work (if you’re a seasonal employee)
- To or from a shelter or other form of transitional housing
Keep reading to learn more about these qualifying life events.
Moving to a different ZIP Code or county
Again, the government and insurance companies tie a few “catches” to this kind of situation.
One is that this move must be permanent. You can’t temporarily move for medical treatments or for a vacation and expect to qualify for a special enrollment period.
Another is that one of the following needs to be true of your relocation:
- You’re moving to an area your current plan doesn’t cover
- You’re moving to an area your current plan covers, but you gain access to new plans due to your change of address
Finally, you must have “qualifying health coverage” for at least one day during the 60 days before your move. Plans that meet this requirement need to provide minimum essential coverage. Thankfully, a lot of common plan types do just that. That’s true whether it’s a job-based, marketplace, off-marketplace, Medicaid, or Medicare plan.
Which health plans don’t offer minimum essential coverage? Plans that only cover dental or vision care. Plans that only cover a specific disease or condition. Plans that only provide discounts on medical services.
Short-term or temporary plans also don’t count as qualifying health coverage, by the way. For more information on these policies, read our article about short-term health insurance.
Moving to the United States from a US territory or foreign country
If you find yourself in this situation and want to switch health coverage (using a special enrollment period), you don’t have to provide proof of this move.
That’s not always the case. In similar situations, like when you add someone to your household or when you lose health coverage, you need to verify your qualifying life event before you’re allowed to use an SEP.
Moving for school or seasonal work
Students who move to or from school can qualify for a special enrollment period.
The same is true if you’re a seasonal employee and you have to move to or from the place you live and work.
Moving to or from a shelter or some other form of transitional housing
Transitional housing exists to help people move from homelessness to permanent housing.
Moving into a shelter or transitional housing qualifies you for a special enrollment period. Moving out of either of these housing situations also makes you eligible for an SEP.
Loss of health insurance
You should qualify for a special enrollment period for health insurance purposes if you lose coverage you got from:
- An employer
- The marketplace set up by the Affordable Care Act
- An insurance company directly (sometimes called “off-marketplace” coverage or plans)
- A parent or other family member
Speaking of that last bullet point, it’s most likely to happen if you’re on your parents’ health plan and you turn 26. You can continue to use their coverage until Dec. 31 of the same year, but you’re on your own after that.
Regarding job-based healthcare, you don’t have to be fired or laid off to be eligible to earn a special enrollment period. You can quit, resign, or retire and become eligible for one, too. In other words, job changes are qualifying life events whether they’re voluntary or involuntary.
You’ll also qualify for an SEP if you lose Medicare, Medicaid, or Children’s Health Insurance Program (CHIP) eligibility.
Other qualifying life events
The above scenarios cover the most common qualifying life events. But they don’t represent all the “changes in situation” that make people eligible for an SEP, though. Here are some other examples, according to healthcare.gov:
- Becoming a US citizen
- Leaving jail or prison
- Starting or ending service as an AmeriCorps member
- Gaining status as an Alaska Native Claims Settlement Act Corporation shareholder
- Becoming a member in a federally recognized tribe
Situations That Don’t Count as Qualifying Life Events
Qualifying life events not only impact your life (as their name implies), but your health insurance, too.
Given that, if you go through an event like the ones discussed in this article but it doesn’t leave you without health coverage, it likely won’t make you eligible for a special enrollment period.
One example of this: say you get divorced. If the health plan you bought or joined before this split still covers you, you’re unlikely to qualify for an SEP.
The same is true if someone in your household dies. As terrible as that situation is, a special enrollment period is out of the question if it doesn’t result in you needing health insurance (because the death left you without it).
You also shouldn’t expect a special enrollment period if you lose your health coverage due to non-payment. Yes, you could argue that’s a “loss of health insurance,” but it’s not treated as a qualifying life event.
Special Enrollment Periods for Complex or Complicated Issues
Qualifying life events aren’t your only avenue to a special enrollment period. Certain complicated or complex issues make you eligible for one as well.
For instance, you should qualify for an SEP if you run into any of these problems while trying to buy health coverage:
- gov displays the wrong data when you go to select a marketplace health plan. That includes benefits or cost information.
- You encounter an error message while applying for a marketplace plan that prevents you from enrolling.
- An agent, broker, or some other official keeps you from enrolling because of “misinformation, misrepresentation, misconduct, or inaction.”
A serious medical condition or a natural disaster also can make you eligible for an SEP. As can these situations:
- You gain a dependent or become someone else’s dependent due to a court order
- You experience domestic abuse or violence
- Your spouse abandons you
- A ruling about a marketplace appeal you filed goes in your favor
Frequently Asked Questions
Q: What if something outside of my control kept me from buying health insurance during open enrollment?
A: It’s possible that “something” is a qualifying life event like the ones described throughout this article. If that’s true, you might be eligible for a special enrollment period.
That “something” also may qualify as one of the complex or complicated issues that make people eligible for an SEP. You can find more information on these issues above.
Q: Do I need to prove I went through a qualifying life event to buy health coverage during a special enrollment period?
A: Yes, in some situations, you will need to provide certain documents before you can qualify for an SEP.
As an example, you may have to send in a birth certificate to prove you added a baby to your family. Or you might need to send in a marriage license to prove you tied the knot.
Some other cases are a bit more complicated. According to Blue Cross Blue Shield, for example, you might have to show “proof of prior qualifying health coverage within the last 60 days” if you’re turning 26 and aging off your parents’ plan.
Proving you lost job-based, Medicaid, or CHIP coverage often requires you to jump through similar hoops. And the same is true if you moved out of a plan area or moved into a new plan area.
You’ll usually have 30 days to provide this proof, by the way, so don’t drag your feet if you want to make use of a special enrollment period.
Q: How can I tell if I qualify for a special enrollment period?
A: The quickest and easiest way to figure out if you qualify for an SEP is to head to healthcare.gov. You’ll find a “screener” there after open enrollment ends. Go through it and it’ll tell you if you’re eligible or not.
Another option is to contact the Marketplace Call Center.
Q: What if I’m turned down for a special enrollment period but I think I should qualify?
A: If you apply for a special enrollment period and it’s denied, file an appeal by following these steps:
- Go to this healthcare.gov page
- Find your state’s appeal form
- Download it
- Fill it out
- Return it electronically or via snail mail (the form you download will tell you how to do this)
Q: What can I do if I missed open enrollment and I don’t qualify for a special enrollment period?
A: The option you’re going to like the least is to wait until the next annual open enrollment period begins.
If you can’t or don’t want to wait that long, see if you’re eligible for Medicaid or CHIP benefits. Your household income needs to be low for you to qualify, but if you do, you don’t need to worry about open or special enrollment periods. You can apply for either of these programs any time of year.
Also, if a job change is what’s causing you to seek out a special enrollment period, consider COBRA coverage. It’s expensive, mostly because you have to pay the full premium for it, but it can be a lifesaver if your only other choices are to wait until you gain access to another employer-sponsored health plan or wait until the next open enrollment period rolls around. To learn more about this kind of coverage, read our article, “COBRA Insurance: What You Need to Know.”
Short-term health insurance is another possibility. Like CHIP and Medicaid, you can apply for this kind of coverage at any time. You don’t have to wait for open enrollment or qualify for an SEP. Before you decide to buy one of these temporary plans, though, read up on the many pros and cons associated with them in our article about short-term health insurance.
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