Having lost coverage in the past 60 days. This encompasses any reason for losing coverage including: losing job based coverage, divorce, death in the immediate family, a child turning 26, losing Medicaid
Losing coverage in the next 60 days. This is the same as above, but the event must be occurring 60 days or less into the future.
Getting married in the past 60 days
Moving to a new home in the past 60 days
Being released from incarceration in the past 60 days
Gaining membership in a federally recognized tribe or status as an Alaska Native Claims Settlement Act (ANCSA) Corporation shareholder
Becoming a U.S. citizen within the past 60 days
Being declined coverage by Medicaid or CHIP
Having a baby in the past 60 days
Adopting a child within the past 60 days
Being misrepresented by an insurance agent or other insuring entity that causes your client to miss their previous SEP opportunity. Please note that this SEP event cannot be submitted via the Benefit Geek platform or the Healthcare.gov website. Your client must call the marketplace to enroll with this event.
All of the above events must have occurred within the past 60 days from the date of enrollment in order for your client to qualify, with the exception of the “Losing coverage in the next 60 days” event. This event must be occurring within the next 60 days of the date of enrollment.
The following events DO NOT qualify your client for SEP:
Voluntarily canceling or terminating coverage
Losing coverage due to failing to pay the premium
Losing marketplace coverage due to a failure to supply the marketplace with required verification documents
Losing Medicaid coverage due to failing to pay the premium
Change in income that does not cause a loss in job-based coverage
Loss of employment that does not result in loss of coverage
Any qualifying SEP event that only applies to your client’s dependent
The following events qualify your client for SEP, but DO NOT qualify your client for a subsidy on their plan:
Declining to enroll in job-based coverage that they qualify for. This applies to coverage offered by your client’s employer or coverage offered through a spouse
Declining to enroll in COBRA if they qualify for it
The following events qualify your client for an SEP ONLY IF THEY ARE ALREADY ENROLLED IN MARKETPLACE COVERAGE. These SEP events must be submitted via a "Life Change" enrollment, and cannot be used via the normal enrollment process.:
A change in income that also changes your client’s subsidy eligibility
Some things to keep in mind regarding SEP events
Providing false information on a marketplace application about an SEP event is misrepresentation of your client and can result in CMS licensing being revoked.
The marketplace does occasionally request verification documents for specific SEP events. If these documents are requested of your client, they will show in the marketplace as requested documents and the enrollment will not be sent to the carrier until the requirement is satisfied.