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Special Enrollment Periods for complex issues

May 1, 2018

Written by

 

After the Open Enrollment Period ends, you can enroll in an insurance plan on or off the Marketplace only if you qualify for a Special Enrollment Period. You can qualify for an SEP if:

  • you have a qualifying life event like having a child, getting married, or losing qualifying health coverage; OR

  • you have a complex issue discussed on this page.

 

Learn more about common Special Enroll Periods

 

 

 

Complex cases that may qualify you for a Special Enrollment Period

 

Exceptional Circumstances

If you faced a serious medical condition or natural disaster that inhibited you from enrolling, you may qualify for an SEP. An unexpected hospitalization, temporary disability, incapacitation, or natural disaster such as an earthquake, massive flooding, or hurricane would qualify as an exceptional circumstance.

 

 

Enrollment or plan information errors on the Marketplace website

If you are subject to misinformation, misrepresentation, misconduct, or inaction of someone working in an official capacity to assist you with your enrollment (such as an insurance company, insurance agent, Navigator, or certified application counselor) and it kept you from either enrolling in a plan, enrolling in the right plan, or getting the premium tax credit or cost-sharing reduction you were eligible for, you may qualify for an SEP.

 

You may have experienced an error message while completing your application that prevented you from enrolling in a plan or prevented your health insurance company from receiving your enrollment information. If you experienced a technical error during your application or enrollment process on the Marketplace or your state's Exchange, you may qualify for an SEP.

 

You may also qualify for an SEP if the wrong plan information was displayed on the Marketplace, or your state's Exchange, at the time you selected your insurance plan. This misinformation may be incorrect coverage information, incorrect cost-sharing information, incorrect provider network information, or incorrect prescription formulary information that led to choosing the wrong plan for you. 

 

 

Previously lived in a state that didn't expand Medicaid and you become newly eligible for help paying for a Marketplace plan because your household income increased or you moved

If you previously lived in a state that did not expand the Medicaid program under the Affordable Care Act and you were not eligible for Medicaid or premium tax credits ("subsidy") because your household income was too high for Medicaid but too low for a subsidy and you are newly eligible for a subsidy because of an increase in your household income within the past 60 days, you may qualify for an SEP. Also, if you moved in the past 60 days and that move caused you to become newly eligible for a subsidy, you may qualify for an SEP.

 

 

Denied Medicaid or CHIP

If you applied for Medicaid or CHIP during Open Enrollment and your state Medicaid or CHIP agency denied your application after Open Enrollment ended, you may qualify for an SEP. You may qualify for this SEP regardless of whether your applied for Medicaid or CHIP through the Marketplace and your information was sent to your state's Medicaid or CHIP agency, OR your you applied through your state's Medicaid or CHIP agency directly.

 

 

Gain or become a dependent due to a child support or other court order

If you gain a new dependent or you became a dependent of someone else due to a child support or other court order, you may qualify for an SEP. Your coverage would start on the effective date of the court order causing the change, even if you applied for coverage up to 60 days following the court order date.

 

 

Experience domestic abuse/violence or spousal abandonment

If you are a victim of domestic abuse/violence or spousal abandonment and want to enroll in your own health insurance plan separate from your abuser, you can enroll by contacting the Marketplace Call Center. If you have any dependents, they may be eligible to enroll as well. If you qualify for this SEP, you have 60 days to enroll.

 

If you are married to your abuser, you can answer on your Marketplace application that you are unmarried, without fear of a penalty for mis-stating your marital status. You may then become eligible for a subsidy or other savings on a Marketplace plan, depending on your income. 

 

 

An appeal decision in your favor

If you believe you received an incorrect eligibility determination or coverage effective date and you filed an appeal with the Marketplace that was determined in your favor, you'll be given the option to enroll in a plan either retroactively or prospectively.

 

 

What to do if you believe you may qualify for an SEP

If you think you may qualify for an SEP for one of the reasons stated above, you need to gather the appropriate information to prepare to file an application and appeal with the Marketplace. Be sure to make copies of any documents that verify your SEP and send only the copies to the Marketplace. Any originals sent to the Marketplace will not be returned.

 

If you are already enrolled in a plan and you win an SEP, you can choose to stay in your current plan or switch plans. In some cases, you may qualify for an earlier effective date of coverage. It is important to remember that you must make your first premium payment before your coverage can become active.

 

How to file an appeal

If your request for an SEP is denied, you can file an appeal with the Marketplace for a redetermination. If the appeal is determined in your favor, you can get coverage back to the date your original SEP was denied.

 

To file the appeal, you need to complete the appropriate appeal form and mail the completed form along with any verification documents to the Marketplace at:

 

Health Insurance Marketplace

Attn: Appeals

465 Industrial Blvd.

London, KY 40750-0061

 

Include a copy of any eligibility determination notice or other notice you received. This will help to process the appeal quicker.

 

When mailing the appeal, be sure to include the last 4 digits of the London, KY ZIP code (40750-0061). This will ensure your appeal form is delievered to the correct address.

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