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What Families Need to Know about Changes in Special Enrollment Periods

Mar 21, 2016

The Centers for Medicare and Medicaid Services (CMS) recently announced two major policy changes related Special  Enrollment Periods in the Marketplace.  Here we will explain what has changed, why, and what consumers need to know.

Can i get coverage outside of open enrollment?Special Enrollment Periods (SEPs) allow consumer to enroll in a Marketplace health insurance plan outside the open enrollment period that occurs near the end of each year.  The most common SEPs are triggered by changes in life circumstances, such as loss of employer-based insurance coverage, marriage, or moving to a new state, but there are other circumstances that trigger SEPs as well.

In January, CMS announced the elimination of certain SEPs and clarified the use of an SEP for a consumer’s relocation.  In February, CMS announced a new process for verifying the need for the most common SEPs.

Elimination of Some SEPs

There won’t be as many circumstances allowed for special enrollment as were previously permitted.  The following are circumstances that will no longer trigger SEPs:

  • Tax-Season
  • Receipt of excess advance premium tax credits due to duplicate policies
  • Errors in Social Security income for dependents
  • Errors in advance payments for tax credits for lawfully-present non-citizens, or delayed processing for individuals with incomes below 100% FPL (federal poverty level)
  • Lack of information about options for coverage under COBRA (Consolidated Omnibus Budget Reconciliation Act --  right to choose to continue group health benefits after employment) 
  • Previous enrollment in the Pre-existing Condition Health Insurance Program

Change in Location

Clarification has been made regarding eligibility for an SEP as it relates to moving to a new location. Special enrollment will be allowed only if the move is intended to be permanent, not temporary.  It is important for families of children with special needs to know that a long-term hospital stay in a different area does not constitute a reason for special enrollment. 

New SEP Confirmation Process

Beginning within the next several months, all consumers who enroll or change plans using an SEP for the followingreasons will be required to provide documentation of the need to use the SEP:

  • Loss of minimum essential coverage
  • Permanent move
  • Birth
  • Adoption, placement for adoption, placement for foster care or child support or other court order
  • Marriage  

Rationale for and Enforcement of the Changes

In addition to requiring documentation for some SEPs, CMS will monitor plans chosen through an SEP to ensure that the special enrollment was justified.  This may include contacting consumers for additional information requests to verify eligibility.  These changes in SEP policies were meant to ensure the proper use of SEPs, so that insurers are not disadvantaged by people misusing SEPs as a means to avoid purchasing insurance until they get sick.  Without such protection, insurers might not be able to offer affordable coverage or might choose to leave the Marketplace.  There still will be special enrollment for individuals who lose coverage due to life changes and other special circumstances. (See resources.)

Resources Factsheet

CMS blogs Enrollment

Center of Budget and Policy Priorities Health Reform Beyond the Basics:  Special Enrollment Periods:

Tags: enrollment, SEPs

Lauren Agoratus


Lauren Agoratus is the parent of a child with multiple disabilities who serves as the NJ Coordinator for Family Voices. She also serves as the southern coordinator in her state’s Family-to-Family Health Information Center.

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