WPS Health Insurance Blog

Special Enrollment Period: Are you eligible?

Posted by Wendy Hathaway

Apr 11, 2018 7:05:00 AM

Household changes are one example of Qualifying Life EventsCertain circumstances make it possible for you to enroll in health coverage outside of the annual open enrollment period, which is the time of year many people can apply for new coverage, change their coverage, or drop coverage.

If you or anyone in your household qualify for a Special Enrollment Period (SEP), you usually have between 31-60 days following what’s called a Qualifying Life Event to enroll in a plan or make changes. Otherwise, you risk having to wait until the next open enrollment period. Read on for examples of the most common Qualifying Life Events. 

Household changes

  • Marriage: If you are newly married, you or your spouse may be eligible. There are a few rules, though. One of you must have had qualifying health coverage for at least one day in the 60 days before getting married in order to add the other spouse. This doesn’t apply if the spouse was living in a foreign country or U.S. Territory, or is a member of a federally recognized tribe.
  • Divorce: You may also qualify if you lost health insurance after legally separating or getting divorced.
  • Death: You may be eligible if you lose health coverage due to the death of a family member.
  • Children/dependents: You may qualify if you had a baby, adopted a child, or placed a child in foster care. Children who join a new household because of child support arrangements or another court order may also be eligible to join a health plan under an SEP.
  • New address: You may qualify if you permanently move to a new residence and your current plan doesn’t provide coverage in that new service area. This includes:
    • Moving to a new ZIP code, county, or state
    • Moving from a foreign country or U.S. territory to the United States
    • A student moving to or from the location where they attend school
    • A seasonal worker moving to or from the place they live and work
    • Moving to or from a shelter or other transitional housing
    • Notes: staying somewhere for vacation or moving solely for medical treatment does not qualify you for an SEP. You also must have had qualifying health insurance for at least one day in the 60 days before moving.

Loss of other health coverage

You don’t qualify for an SEP if you choose to end your coverage voluntarily, if you didn’t pay your premium, or if you didn’t have what qualifies as “minimum essential coverage” under the Affordable Care Act. However, if you lost coverage for other reasons, or expect to lose coverage in the next 31-60 days, you may qualify.

You may be eligible for an SEP if:

  • You are no longer covered through a job, including if your employer stops offering coverage or if the coverage doesn’t qualify as minimum essential coverage.
  • You were covered under a parent’s health plan, turn 26, and lose coverage.
  • You or your dependents are no longer eligible for Medicaid (e.g., due to income changes) or the Children’s Health Insurance Program (CHIP) (e.g., due to aging out of the program).

Other circumstances

There are other life changes that may make you eligible for a Special Enrollment Period.

  • New job: If you’re a new employee and your employer offers group health insurance, you may apply right away instead of waiting for the next annual open enrollment period (unless you qualify for an SEP under other circumstances). For example, WPS Health Insurance group health plans require you to apply within 31 days of becoming eligible for coverage.
  • U.S. citizenship: You may qualify for coverage if you’ve just become a U.S. citizen.
  • End of incarceration: You may qualify after being released from detention, jail, or prison.
  • Domestic abuse: You may be eligible for an SEP if you or your dependents are the victim of domestic abuse/violence or spousal abandonment, and want to enroll in coverage separate from the perpetrator.
  • American Indian or Alaska Native tribe member: Members of federally recognized tribes, as defined by the Indian Health Care Improvement Act, and Alaska Native Claims Settlement Act (ANCSA) Corporation shareholders may enroll in, or change, from one plan to another, up to once a month.

This is not a complete list of the Qualifying Life Events that make you eligible for Special Enrollment Periods. Visit healthcare.gov to learn more.

Be sure to check your WPS Health Insurance policy for exact eligibility and effective dates and if you have questions about SEP qualifications, or anything else relating to your coverage, please contact Member Services at the phone number on your customer ID card, Monday through Friday, 7:30 a.m.–5 p.m. CT.

Source: Centers for Medicare & Medicaid Services Health Insurance Marketplace.

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Topics: health insurance, Individuals & Families, special enrollment period