You just moved to a new state. Your wife just had a baby. Your employer just decided not to offer health insurance. You just got a new job without health insurance and no longer qualify for Medicaid. Your employer sponsored premium just shot through the roof and is on its way to the stratosphere. What do all these circumstances have in common? They are all Qualified Life Change Events (QLCE) which open Special Enrollment Periods.
So, now what? Well, it depends – like so much in life. In this case it depends on whether or not you already have an enrollment through the Marketplace. Having or adopting a child is a QLCE and in many cases will allow a change of plans. At the very least, the new young ‘un needs to be added to the existing plan – the SEP allows this to happen.
So what’s an SEP anyway? A Special Enrollment Period is a 60 period of time in which you are allowed to enroll outside of Open Enrollment due to a Qualified Life Change Event. Clear as mud? Let’s translate it into English.
An SEP is just a window of time where you are allowed to enroll that isn’t during Open Enrollment. It only lasts 60 days from the date of the QLCE that opened the SEP.
AKA: To get an SEP you have to have a QLCE.
Example: Marty was on Medicaid while unemployed. He started a new job on June 1st but that job doesn’t offer health insurance. He now makes enough money that on June 31st Marty will lose his Medicaid. Can Marty enroll with the Marketplace?
Yes – loss of Medicaid is a QLCE. Since Marty has a QLCE, he also has a SEP. When does his SEP begin? Technically, it begins June 31st because that is the date he will no longer have Medicaid – but if he doesn’t enroll before June 31st he won’t have coverage on July 1st. For that reason, Marty is allowed to go ahead and enroll in June – but his coverage won’t begin until July 1st. In most cases, once he is enrolled, his SEP ends – he cannot go back and change plans the way he would be able to in Open enrollment.
Jane already has a Bronze plan through the Marketplace. She gives birth on May 25th to a bouncing baby boy. Can Jane add her newborn to her plan? Yes, birth is a QLCE so her bouncy boy, BB, has a SEP and can enroll.
But Jane didn’t plan on a baby when she enrolled and doesn’t think the plan she has is adequate to her new circumstances. Can she change plans? In most cases, yes – she can change plans at the time she adds BB. In some states, she may have to settle for enrolling BB in a different plan from her own so he has the coverage she wants for him.
Jane calls the call center a month after BB is born – can he still enroll? Yes – his SEP is 60 days from May 25 – his date of birth. His coverage, unlike that of an adult being added to a plan, will begin on his date of birth. But Jane’s husband’s plan will cover BB until June 31st and she doesn’t need the Marketplace plan to begin until July 1st. This is trickier but can be done since BB is losing coverage on June 31st – in this case BB actually has two QLCEs and his parents are opting to use the second one, loss of coverage. In this case, letting the experts at the call center do the enrollment is probably best.
Finally, Tim moved to the state on June 1st but with the move and other problems he didn’t get around to enrolling until September 1st. Can Tim still enroll? Unfortunately, the short answer is no. Tim’s QLCE is new resident – and his SEP began June 1st. It ended 60 days later. September 1st is more than 90 days later – Tim’s SEP is long over. In most cases, Tim will not be able to enroll unless he happens to have another QLCE or until Open Enrollment for the following year.
Tim can appeal for a new SEP – it depends very much on circumstances whether he will get one. If Tim can show that he really could not enroll before September 1st he might be granted a new SEP – but these are rare.
Of course there is one exception to that rule – if Tim is unable to enroll because of something beyond his control and/or a problem with the Marketplace – for example he completes an application on July 1st but doesn’t receive a determination until September 1st. This is a problem on the Marketplace and nothing Tim could have affected. Tim will be allowed to enroll in this instance.
Pro Tip: if something goes wrong and you can’t enroll when you intended to – call the call center immediately, even if it’s something you think you can handle. Get the problem documented – this helps insure that you will be allowed to enroll if things go really wrong!