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Special Enrollment Period Guide

Here’s everything employers, employees, and HR professionals need to know about Special Enrollment Periods (SEP) for health insurance. 

Overview

What is a Special Enrollment Period (SEP)?

An SEP, or Special Enrollment Periodrepresents a span of  time outside of the annual Open Enrollment Period (which takes place from November 1-January 15) and provides an opportunity for individuals to select new individual health insurance plans mid-year. 

Overview: What Is An SEP for Health Insurance?

Utilize your chance to change plans mid-year.

As you have explored your healthcare options, you may have wondered “what is an SEP for health insurance?” An SEP, or special enrollment period, represents a span of  time outside of the annual Open Enrollment Period. Open Enrollment takes place from November 1-January 15 and provides an opportunity for individuals to select new individual health insurance plans for the calendar year. 

After Open Enrollment ends, individuals can only change plans if they qualify for a special enrollment period (SEP). It’s important to note that an SEP applies solely to individual health insurance plans that are purchased through the Health Insurance Marketplace. In order to take advantage of an SEP, there are many unique factors that must be considered.

What Makes Me Qualified for an SEP?

Five primary factors qualify you for an SEP.

There are five primary life changes that can qualify individuals for an SEP. These life events include loss of qualifying healthcare coverage, change in household size or primary place of living, change in Marketplace eligibility, and error in enrollment or health plan. 

Let’s examine real-life examples of these events to better understand the qualifications for an SEP. 

1. Loss of Qualifying Healthcare Coverage

An individual can lose their healthcare coverage for a variety of reasons. Job loss, whether it is voluntary or involuntary, may qualify an individual for an SEP because it would mean the employee no longer has access to the employer-sponsored health plan. Loss of healthcare coverage can also be represented through an employer no longer offering employee healthcare or switching to providing coverage that is not considered qualifying coverage. According to HealthCare.gov, you may only be eligible for an SEP if you or someone in your household has lost coverage in the past 60 days or expects to lose coverage in the next 60 days.

2. Change in Household Size

Another factor that may qualify an individual for an SEP is a change in household size. Major life events such as:

  • marriage
  • death of a family member
  • having a baby
  • adopting a child
  • placing a child in foster care
  • or changes surrounding child support/court orders

These factors are all considered changes that may qualify you to select new individual plans.

3. Change in Primary Place of Living

If you’ve recently moved, applying for an SEP could be beneficial for you and your household! Permanently moving to a different county or an area with a different ZIP code is a life change that could qualify someone for an SEP. Other living changes such as moving during seasonal employment, moving to the United States from a different country, moving to where your school is located, or moving from transitional housing are also considered changes in a primary place of living. Just keep in mind that vacations and moving for medical treatments are not qualifying events. 

4. Change in Eligibility for Marketplace Coverage or Help Paying for Coverage

This event occurs when an individual is newly eligible or ineligible to pay for healthcare coverage. Many factors such as moving, becoming an American citizen, being released from incarceration, or becoming a member of a federally recognized tribe may lead you to qualify for an SEP in this way.

5. Enrollment or Plan Error

Although this occurrence is extremely rare, if you believe that there was an error during the enrollment and plan selection process through the Health Insurance Marketplace, you may be eligible for an SEP. Enrollment or plan error can look like not being enrolled in a plan or mistakenly being enrolled in a different plan. These issues can be attributed to misinformation or technical errors, and it is crucial to inform the Marketplace if you were enrolled in the wrong plan.

What Kind of Plan Can I Get During a Special Enrollment Period?

Qualify for individual health insurance.

The advantage of qualifying for a special enrollment period is that you get to enroll in a new individual health insurance plan through the Health Insurance Marketplace. The Health Insurance Marketplace is located at HealthCare.gov and allows individuals to shop for the individual health insurance plan that best fits their needs! With individual health insurance, you can choose a budget-friendly plan that provides excellent coverage for your household. 

How Do I Apply for an SEP?

Apply for an SEP online.

If you believe you meet the qualifications for an SEP and are ready to select a new plan, it’s time to apply! First, visit this link to answer a few quick questions and complete the Marketplace application. Then, if you meet the qualifications, you will be able to view plan options and prices. This application is an important step in notifying the Marketplace about your eligibility for an SEP. If you do not complete the application, the Marketplace will not be aware of your desire to utilize a special enrollment period and you will not be able to enroll in a new plan until the next annual Open Enrollment period. 

What Documents Do I Need for a Special Enrollment Period?

Submit all relevant documentation depending on your circumstances.

After applying for an SEP, you may need to submit documents to confirm your eligibility. The required documentation that needs to be submitted to HealthCare.gov is dependent on your specific circumstances. For example, if you recently changed your primary place of living, you may have to submit bills or mortgage documents that include your name and the date you moved. 

Other documents such as letters from your previous insurance provider, pay stubs, or legal records may also be required for submission. You have 30 days to submit all required documents to the Marketplace, which can be submitted online or sent by mail.



How Long Is a Special Enrollment Period?

Apply on time for your SEP.

Most SEPs are either 60 days before or 60 days after the specific qualifying life event occurs. However, job-based plans must provide a minimum SEP of 30 days. If your state of residence runs its own Health Insurance Marketplace, there may be different Special Enrollment Periods. In order to avoid being uninsured, it’s important to know exactly how much time you have to choose your new plan. To find out more information about an SEP, visit HealthCare.gov or call 1-800-318-2596

I Didn’t Qualify for an SEP. What’s Next?

Appeal the outcome or wait for Open Enrollment.

If you applied for an SEP and the Marketplace determined that you were not eligible, you can file an appeal. You have 90 days to file this appeal and request reconsideration. If you decide not to appeal this decision, you’ll have the opportunity to enroll in an ACA-compliant plan during Open Enrollment. Not being eligible for an SEP may feel discouraging, but thankfully, you have options to make sure your healthcare coverage is secured. 

How Do I Cancel My Current Plan?

Individual insurance allows you to cancel at any time.

If you are currently enrolled in a traditional group health insurance plan through your employer, you can only cancel your plan during the Open Enrollment period. However, if you have individual health insurance through the Marketplace, you can cancel your plan at any time! This is just one of the many benefits and conveniences of switching to individual plans! 

Canceling your individual health insurance plan is as simple as logging into your account or calling the Marketplace to inform them of your decision.

Get in touch with our team of experts.

Get in touch with our team of licensed experts.

Do you have questions about SEPs, the Marketplace, or enrolling your org in a new individual health insurance plan? We are here to help and guide you every step of the way! Our licensed experts can help you find the best plan and navigate the complex world of healthcare. With Remodel Health’s proprietary health benefits software, you can also easily manage your employees’ individual health insurance. The key benefits of our software include tax calculations, shopping and enrollment assistance, year-round support, and so much more. 

Connect with us to learn more about how to improve your health benefits and experience the freedom of individual health insurance!

Wondering if Your Employees Qualify for an SEP?

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