Trying to enroll in a major medical plan after Open Enrollment (Nov 1-Dec 15 each year) requires a qualifying life event to trigger a Special Enrollment Period. There are several life changes that can qualify you for a Special Enrollment Period and they revolve around: changes in household size, changes in residences, loss of coverage, and becoming eligible for QSEHRA or ICHRA reimbursements.
Changes in household
You may qualify for a Special Enrollment Period if you or anyone in your household in the past 60 days:
Got married
Had a baby, adopted a child, or placed a child for foster care
Got divorced or legally separated and lost health insurance. Note: Divorce or legal separation without losing coverage doesn’t qualify you for a Special Enrollment Period.
Death. You’ll be eligible for a Special Enrollment Period if someone on your Marketplace plan dies and as a result you’re no longer eligible for your current health plan.
Changes in residence
Household moves that qualify you for a Special Enrollment Period:
Moving to a new home in a new ZIP code or county
Moving to the U.S. from a foreign country or United States territory
A student moving to or from the place they attend school
A seasonal worker moving to or from the place they both live and work
Moving to or from a shelter or other transitional housing Make sure to provide proof of your residence change, such as a utility bill, lease agreement, or updated driver’s license, and ensure you had qualifying health coverage for at least one day during the 60 days prior to your move, except when moving from a foreign country or U.S. territory.
Change-of-address confirmation from the U.S. Postal Service (USPS).
Note: Moving only for medical treatment or staying somewhere for vacation doesn’t qualify you for an SEP.
Important: You must prove you had qualifying health coverage for one 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 United States territory.
Necessary documentation includes utility bills, lease agreements, or updated driver’s licenses to validate a residence change.
Loss of health insurance
You may qualify for a Special Enrollment Period 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.
Coverage losses that may qualify you for a Special Enrollment Period:
Losing job-based coverage
Losing individual health coverage for a plan or policy you bought yourself
Losing eligibility for Medicaid or CHIP
Losing eligibility for Medicare
Losing coverage through a family member
Turning 26 and losing coverage under a parent’s health insurance plan.
You must provide a letter from your previous insurance provider or employer, stating the individuals losing coverage and the effective date.
More qualifying changes
Other life circumstances that may qualify you for a Special Enrollment Period:
Changes that make you no longer eligible for Medicaid or the Children’s Health Insurance Program (CHIP)
Gaining membership in a federally recognized tribe or status as an Alaska Native Claims Settlement Act (ANCSA) Corporation shareholder
Becoming newly eligible for Marketplace coverage because you became a U.S. citizen
Leaving incarceration
AmeriCorps VISTA members starting or ending their service
Becoming newly eligible for a QSEHRA or ICHRA
Becoming newly eligible for employer-sponsored benefits like an Individual Coverage Health Reimbursement Arrangement (ICHRA). Ensure you enroll within 60 days of becoming eligible.
What Documents Are Required for Proving Eligibility for a Special Enrollment Period (SEP)?
Special Enrollment Period (SEP) eligibility often requires documentation to verify qualifying life events (QLEs). Below is a detailed guide to the documentation typically required:
Documentation for a QLE Due to a Move
If your QLE is based on moving to a new address, you need to provide the following:
Proof of the Move
A utility bill
Lease agreement or rental contract
Change-of-address confirmation from the U.S. Postal Service (USPS)
Proof of Prior Health Coverage
A document proving that you had health insurance coverage for at least one day within the 60 days prior to your move.
Note: This requirement does not apply if you are moving from outside the United States or a U.S. territory.
Non-Qualifying Scenarios for Moves
Moves solely for medical treatment or vacation purposes do not qualify for an SEP under a move-related QLE.
Documentation for Other QLEs
Loss of Coverage: Provide a letter from your previous insurance provider or employer. The letter must state which individuals lost coverage and the effective date.
No Prior Insurance: No separate document is required to prove the absence of prior insurance. Your eligibility will depend solely on the proof you provide for the qualifying life event.
Eligibility Beginning Without a Separate QLE: If no additional QLE is needed and you're newly eligible, you may still be required to follow these steps:
Cancel your current plan (if applicable).
Request an account reset (if needed) via your benefits platform.
Purchase a new plan with your eligibility through the marketplace.
Submit proof of coverage for compliance review.
Requirements for Proof of Coverage Documentation
Documentation proving prior or current coverage should include:
Your name (or a notation that you are a covered dependent).
Premium amount (if claiming reimbursement).
A current date, typically within the last 30 days.
Statement of backdated coverage for past-month premium claims (if applicable).
Plan name and provider details, such as the plan's metal tier or insurance carrier name, ideally as listed on your monthly bill or election of benefits document.
Frequently Asked Questions (FAQs)
Should I Self-Enroll During a SEP?
If your coverage and documents are already approved, you can self-enroll during your SEP for quicker plan activation and to minimize delays.
Need Additional Support?
For further assistance on qualifying life events and enrollment steps, contact your benefits administrator or health insurance provider.