This article was published by Directive Health’s sister company, American Exchange.
When good things brighten your life, like getting married or having a baby, or bad things happen, like losing your job-based health insurance, they are considered life-changing events. Certain life-changing events qualify you for a special enrollment period (SEP) outside of the Affordable Care Act (ACA) open enrollment period, which ended January 15, 2023.
What is an ACA SEP?
A SEP is a limited window of time you have after a qualifying life-changing event to buy or change your ACA health plan.
What Qualifies as a Life-Changing Event?
There are 6 categories of life-changing events that may qualify you for a SEP:
- Household changes
- Loss of insurance coverage
- An employer offers to help with the cost of coverage
- Income Below 150% of the Federal Poverty Level (FPL)
- Other changes
View an infographic of the ACA SEP life-changing events.
You may qualify for a SEP if you or anyone in your household, in the last 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 in foster care:
- Your coverage can start the day of the event, even if you enroll in the plan up to 60 days afterward
- Got divorced or legally separated and lost health insurance:
- You do not qualify for a SEP if you do not lose your health coverage
- You’ll qualify for a SEP if someone on your plan dies, causing you to lose your current health coverage
You may qualify for a SEP if you move your residence to:
- A new ZIP code or county
- The United States from a foreign country or US territory
- To or from:
- The place you attend school, if you’re a student
- The place you both live and work, if you’re a seasonal worker
- A shelter or other transitional housing
To be eligible for a SEP, you must prove you had qualifying health coverage for one (1) 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 US territory. Moving only for medical treatment or staying somewhere for vacation doesn’t qualify you for a SEP.
Loss of Health Insurance
You may qualify for a SEP 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. Circumstances include:
- Losing job-based health coverage through your or a family member’s employer, including if you are covered through a parent or guardian because you’re no longer a dependent
- Voluntarily dropping coverage you have as a dependent doesn’t qualify you for a SEP unless you also had a decrease in household income or a change in your previous coverage that made you eligible for savings on an ACA plan
- Losing individual health coverage, including if:
- Your individual plan or ACA plan is discontinued
- You are no longer eligible for a student health plan
- 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
- Your household income decreased, and now you qualify for savings on an ACA plan
- Losing coverage through a family member, including if:
- You turn 26 (or the maximum dependent age allowed in your state) and can no longer be on a parent’s plan
- A family member loses health coverage for their dependents
- A divorce or legal separation
- The death of a family member
- You’re no longer a dependent
- Losing premium-free Medicare Part A coverage:
- You don’t qualify for a SEP if you lose Medicare Part A because you didn’t pay your Medicare premium or lose Medicare Parts B or D only
- Losing or were denied Medicaid or Children’s Health Insurance Program (CHIP) coverage because:
- You are no longer eligible
- Your child ages off CHIP
- You applied for Medicaid/CHIP or ACA coverage during Open Enrollment or with a different SEP and were told you might be eligible for Medicaid/CHIP. But when your state agency told you that you weren’t Medicare or CHIP eligible, ACA Open Enrollment or your Special Enrollment Period had ended.
If you have been told or think you may lose coverage during the Medicaid unwinding currently taking place, read our blog, Act Now if You Have Medicaid, CHIP, or BHP Coverage, to see what you need to do.
An Employer Offers to Help with the Cost of Coverage
You may qualify for a SEP if you or anyone in your household were offered an individual coverage HRA or a Qualified Small Employer Health Reimbursement Arrangement (QSEHRA) in the past 60 days or expects to in the next 60 days. Your employer may refer to an individual coverage HRA by a different name like “ICHRA.”
Please note that you cannot enroll online in this situation. You will need to have an independent insurance agent (like American Exchange), navigator, or the Marketplace assist you.
Income Below 150% FPL
You can enroll in an ACA health plan during this year-long, low-income SEP if you and your dependents are eligible for advance premium tax credits and have a household income under 150% FPL (click here to see FPL chart for Plan Year 2023). If you are a lawfully present immigrant who qualifies for tax credits, you are also eligible to enroll any time.
Other Situations that May Qualify You for a SEP
- Gaining membership in a federally recognized tribe or status as an Alaska Native Claims Settlement Act (ANCSA) Corporation shareholder
- Becoming a U.S. citizen
- Leaving incarceration
- Starting or ending service as an AmeriCorps State and National, VISTA, or NCCC member
Do I Need to Prove that I am Eligible for an ACA SEP?
You may. After you pick a plan, you will receive a Marketplace® Eligibility Notice. If your eligibility notice doesn’t say you need to submit documents, you don’t have to.
If the notice tells you to send documents to confirm eligibility:
- You have 30 days to upload or mail the required documents
- See how to upload or mail documents
- Your coverage won’t start until you send the documents and your eligibility is confirmed
Need help finding an ACA plan?
If you aren’t sure if you qualify for a SEP or just want help finding the best ACA plan for your budget, health, and lifestyle needs, American Exchange is here for you. Our licensed, independent health insurance benefits experts will listen to your needs, then compare all plans available in your area at no cost or obligation to you. Contact us today.
Visit our ACA insurance for individuals and families web page.
Our compassionate agents are available to speak with you:
Monday through Friday from 8:00 a.m. to 5:00 p.m. Eastern
You may also be interested in:
- Your Family Could Qualify for ACA Health Plan Subsidies Even if You’re Working
- Subsidies Help Lower Your ACA Health Plan Costs
- Health Insurance Terms
- Understanding ACA Metal Plans
American Exchange is a licensed health insurance broker. Robert Huffaker, NPN 13568432
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