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    What is a Special Enrollment Period & What Qualifies?

    5 mins

    Wouldn’t it be nice if getting health care were like ordering takeout? Think of the process more like waiting for the bus, where you have specific times you’re able to get on board.

    Usually, when you want to sign up for health insurance or change your insurance, you have to wait for an Open Enrollment Period. But, there is a way to apply for or make changes to your health insurance. If you meet the criteria for certain life events, you may apply for a Special Enrollment Period (SEP). What is a Special Enrollment Period?

    Think of it as a way to sidestep the usual enrollment period requirements. An SEP does have specific qualifications, however. If any of the following scenarios apply to you, you might be eligible.

    Changes in Family

    Let’s say the number of people in your household changes. This could be due to:

    • Marriage: Whether you or someone else in the house got married, you have until the end of the month to sign up for coverage to begin the first of the following month.

    • New Child: Having a baby or adopting/fostering grants you coverage that very day.

    • Divorce/Separation: The household member with health insurance leaves and no longer covers anyone else with their insurance. If coverage is not lost, this does not count as a Special Enrollment Period qualifying event.

    • Death: You’re eligible if you lose insurance due to the death of the primary insured.

    If you qualify for any of these, you now have a thirty-day window to apply for insurance. Note that some of these may not apply depending on your job’s enrollment rules. You may not have to worry about asking, “what is a special enrollment period” because open enrollment might be longer than you think. Ask your employer, and you may be pleasantly surprised to find out you’re actually in the window to sign up.

    Housing Situations

    If you’re changing residences, you might qualify. Moving across the street doesn’t count (unless it somehow crosses a county line!), nor does going on vacation or staying at a facility for medical treatment. To qualify, you’ll need to:

    • Change zip code or county residence

    • Move to a new country or US territory

    • Change residence for school

    • Enter transitional housing

    • Move for seasonal work

    You’ll also need to prove you had health insurance for at least one day in the sixty days before moving. If you’re moving out of the country, you won’t need to provide any proof.

    Lost Insurance

    If you lose eligibility for Medicare, Medicaid, or CHIP, your job-based coverage, or a privately purchased health plan, you qualify for Special Enrollment and have thirty days to find a new plan. You’ll also qualify if you expect to lose your insurance within thirty days.

    Voluntarily dropping your coverage as a dependent doesn’t count, however, unless you experienced another valid life event as well. Legitimate reasons for losing your insurance can include:

    • Discontinuation of your plan by provider

    • Provider ceases to operate

    • Your plan expires, and you choose not to renew

    • Your household income decreases, and you now qualify for a Marketplace plan

    • Eligibility expires for a student health plan

    • Your child ages out (specifically CHIP)

    • You’re no longer eligible for premium-free Medicare Part A

    • You are no longer with your employer and don’t have access to their plan through COBRA coverage (this can sometimes occur with small employers)

    For dependents, remember that the maximum age for coverage by a parent or guardian’s plan is 26 years. For those under 26, you can still lose insurance due to a parent/guardian’s death, divorce, or other life events.

    Coverage Assistance

    A Health Reimbursement Agreement (HRA) is when an employer agrees to pay a certain amount for qualifying medical expenses. You may even be able to use the money to buy insurance. An HRA isn’t meant to be or take the place of insurance, and under some HRA plans, you’ll need to have insurance to qualify.

    Some small businesses use a Qualified Small Employer HRA (QSEHRA) instead of actual health insurance offerings. To use the QSEHRA, you or your household members must sign up for minimum essential coverage (MEC). That could be Medicare or Medicare Advantage, a family member’s health insurance, or Marketplace Coverage. 

    There are other types of HRAs called Individual Coverage HRAs (ICHRAs) or Excepted Benefit HRAs (EBHRAs) which can also be offered through your employer. Each has different rules for how the money can be used.

    Regardless of what type of Health Reimbursement Agreement your employer offers, simply having an HRA established through your employer may qualify you for a Special Enrollment Period.

    Status Change

    Certain alterations to your U.S. citizenship may qualify or disqualify you. You could be eligible for an SEP if:

    • You’ve been released from prison

    • You become a recognized tribe member in the Alaska Native Claims Settlement Act Corporation

    • You become a US Citizen

    • You begin or end service with VISTA, Americorps State and National, or NCCC

    If the government revokes your US citizenship or you’re otherwise stripped of citizen status, the question of “what is a special enrollment period” won’t apply to you!

    Other Circumstances (Medicare)

    If you find yourself in a situation not described above, you could still qualify for an SEP when enrolling for Medicare. Some other reasons for eligibility include:

    • You lost coverage due to an error by a federal employee

    • You were given inaccurate information about Medicare Coverage

    • You’re eligible for both Medicare and Medicaid

    • You dropped Medigap coverage the first time you enrolled in a Medicare Advantage Plan

    If you made the wrong plan choice, this isn’t the end of the world, thankfully. You can call 1-800-MEDICARE to get assistance and find options for making a change.

    Further Assistance

    If you’re still in need of further clarification as to what qualifies as a Special Enrollment Period, that’s ok! There are many extenuating circumstances, and no one article can cover every situation. If you’re curious about whether you qualify, you can find out directly from the government, where will help you determine if you meet the criteria.

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    Ben Koubek
    Regional Sales Manager at Bennie

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