Special enrollment periods (SEPs) are nothing new. For health insurance agents working with groups, HIPAA regulations have meant that employees and family members who originally waive coverage on a group plan have special enrollment rights if they lose other qualified coverage or have a life event such as marriage, birth or adoption. During these special enrollment periods, employees and their family members usually have 30 days to sign up for the group health plan.
Agents who sell to Medicare beneficiaries are also familiar with SEPs. When someone over the age of 65 has postponed enrollment in Medicare because he is still working and covered under a company’s group health plan, he can sign up for Medicare Part A and/or Part B at any time. He also has an eight-month SEP after his current employment or group coverage ends. Additionally, there are a number of events that would trigger a special enrollment opportunity for Medicare Advantage or Medicare Part D Prescription Drug Plans. Learn more here.
Something dramatically different and new in the world of special enrollment periods is that they now exist in the individual market as well, a side effect of the open enrollment periods instituted by the ACA. These can be a little confusing for agents because the SEP rules for plans purchased off the federal or state exchanges aren’t the same as the rules for plans purchased on the exchanges. Let’s focus on the Marketplace rules here to keep it simple and because they offer the greatest opportunity to enroll individuals outside of the annual open enrollment period.
As Healthcare.gov explains, “After February 15, 2015, you can enroll in a 2015 health insurance plan only if you have a life event that qualifies you for a Special Enrollment Period.”
Here’s a list of life events that may qualify your clients for SEPs:
- Getting married
- Having a baby
- Adopting a child or placing a child for adoption or foster care
- Losing other health coverage, like coverage through an employer or Medicaid
- Having a change in income or household status that affects eligibility for premium tax credits or cost-sharing reductions
- Moving to a new residence
- Gaining citizenship or lawful presence in the U.S.
- Leaving incarceration
Some of these require further explanation.
This is pretty straightforward, but it is worth mentioning that the Supreme Court’s recent ruling on same sex marriage means that any legal marriage in any state will qualify the couple for an SEP in the individual market. The new couple may also find that their combined incomes and larger family size now make them eligible for a premium tax credit.
Having a baby, adopting a child or placing a child for adoption or foster care
When a child is born, adopted or received into foster care, the entire family can use the special enrollment period to enroll in coverage; the SEP is not restricted to the new addition to the family. Furthermore, if you place your child for adoption or foster care, that creates a special enrollment period to enroll in coverage.
Losing other health coverage
This could happen for a number of reasons, and almost any of them would qualify the affected individuals for a Special Enrollment Period. For instance, the company that employs your client could stop offering coverage altogether, as some small employers have decided to do in the last couple years. Employers undertaking this tactic could increase significantly if new defined contribution legislation is passed. [link to copy of newsletter article] The employee could also quit his or her job, get fired or laid off, experience a reduction in work hours that makes him or her ineligible for coverage or be moved to a non-benefits-eligible job classification.
Additionally, choosing not to re-enroll in coverage at the plan’s open enrollment period would create an SEP for employees and their covered family members, as would the employee becoming newly eligible for a premium tax credit because the group plan does not meet the definition of “affordable” or “minimum value.”
Several other situations could cause the employees’ dependents to lose group health coverage and therefore qualify them for SEPs, such as losing coverage through a divorce; the expiration of COBRA coverage; turning 26 and losing coverage under a parent’s plan or losing eligibility for Medicaid or the Children’s Health Insurance Program (CHIP).
Voluntarily terminating coverage, such as cancelling COBRA before the end of the continuation period, will not create a special enrollment opportunity.
Moving to a new residence
Generally, moving to a new residence would create a special enrollment opportunity if your client moves out of her existing plan’s service area or move within the state but gain access to at least one new health insurance plan as a result.
Enrolling or changing coverage during a special enrollment period
If your client is not yet enrolled in coverage, he or she can sign up online at Healthcare.gov or through the state exchange website. Make sure they have your agent info so you’ll get credit for the sale. A phone enrollment option is also available. Some carriers will also allow you to enroll your clients through their website, which some people find to be easier if they already know which insurance company they want to go with.
If your client already has coverage but wants to make a change during a Special Enrollment Period, this can be done through the Marketplace or with the carrier, depending on where he or she first enrolled.
The SEP usually lasts for 60 days, though there are some exceptions. For instance, as ObamacareFacts.com explains: “Job-based plans must allow special enrollment periods of 30 days (giving you no less than 30 days of coverage while you switch to a Marketplace plan).” This would usually overlap with the group plan’s open enrollment period. Some special enrollment periods, while continuing for 60 days following the qualifying event, will actually allow you to begin the enrollment process up to 60 days before the event, giving you almost four months to sign up. A loss of group coverage because an adult child turns 26 is a good example. Finally, states that operate their own marketplace have the flexibility to expand special enrollment opportunities for consumers as they choose.
It should also be mentioned that members of federally recognized Indian Tribes or Alaska Native shareholders can enroll in or change plans once per month any time of year (not just during Open Enrollment). There is also no special enrollment period for government-offered coverage options like Medicaid or CHIP; qualified individuals can apply at any time.
Want to learn more?
To learn more about SEPs, we’d recommend that you take a look at the Healthcare.gov SEP Screener. The video below also provides a basic overview of Marketplace SEPs.