For most people, insurance plans are only available through the Affordable Care Act (ACA) Insurance Marketplace up until a certain deadline. This deadline for 2021 is later than usual (August 15th) due to the COVID-19 pandemic. If you did not purchase health insurance or are not previously covered, you might apply during the Special Enrollment Period if you have a qualifying life event.
Mira may be an option for you if you still need insurance but do not meet the Special Enrollment Period application requirements. Mira is not traditional insurance but rather offers benefits through a care membership program. You can get urgent care visits for $99, up to 80% discounts on prescriptions, and same-day lab tests by becoming a member. Sign up to become a member at Mira and start your benefits today.
What the Special Enrollment Period (SEP) Is
The Special Enrollment Period (SEP) is a specially requested period of time when a person seeking insurance can still qualify for coverage after the ACA Health Insurance Marketplace open enrollment period has closed. This period of time is not available for just anyone, but you must meet specific requirements to request your enrollment period be extended.
Qualifying Life Events
To qualify for a SEP, you must meet the requirement of experiencing any of the following qualifying life events (QLE).
Loss of Qualifying Health Coverage
If you lose your health coverage for any of the following reasons, you are automatically eligible to apply for the SEP:
- Losing coverage from your parents (such as when an individual turns 26)
- Loss of eligibility for Medicaid, Medicare, or the Children’s Health Insurance Program (CHIP)
- Losing employer-sponsored health insurance
- Losing student health insurance
Change in Household Structure
If the number of individuals in your household changes, you may have different health care needs and thus may not be suited for your former insurance plan. In this case, you also qualify to search for a marketplace plan under the SEP. Qualifying household changes include:
- Having a baby
- Getting married/divorced
- The death of a previously covered family member results in you no longer being required for your current plan.
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Changes in Residence
Often when you change your residence, you may not qualify for some health insurance plans, and/or there may be no providers in your area. You will qualify for a SEP if you meet any of the following criteria:
- Changing zip codes or counties
- Moving work locations as a seasonal worker
- Being a student that is moving to or from school
- Moving to or from a shelter (such as a homeless shelter or women’s shelter)
Miscellaneous Qualifying Life Events
Other QLE that make an individual eligible for the SEP include:
- Becoming a United States citizen
- Leaving jail or prison
- Income changes that qualify or disqualify you from your current insurance
- Starting or ending service as an AmeriCorps or Peace Corps member (i.e., seasonal employment) as well as a VISTA or NCCC member
- Gaining membership to a federally recognized indigenous tribe
- Claiming status as a Corporation shareholder under the Alaskan Native Claims Settlement Act (ANCSA)
- Newly acquired access to an individual coverage health reimbursement arrangement (HRA) or a qualified small employer health reimbursement arrangement (QSEHRA).
Applying for the Special Enrollment Period
To apply for the SEP, you must create or update your account with the ACA Health Insurance Marketplace. You can begin to complete the application if you have lost your coverage within the last 60 days or anytime after January 1, 2021.
You can also apply if you expect to lose your coverage within the next 60 days. If you end up not losing your coverage in that period of time, you will no longer qualify for insurance through the SEP.
You can start the application by going to the Health Insurance Marketplace website. You can search through the currently available plans and prices before applying. It can be wise to choose a plan and prepare the necessary documents for the application before filling out the application.
Documents that you may need to apply vary depending on what factors qualify you for the SEP. Some of the documents you may need include but are not limited to:
- Notification of previous coverage ending
- Documents that qualify your coverage include - notice from the insurance company, a letter from your employer, a letter about COBRA coverage, documentation of a health care program (Medicare, Medicaid, or CHIP), multiple pay stubs showing reduction of work hours, death certificate of a family member, or a marriage/divorce certificate.
- Proof of residence in a new location
- Gain of dependency via adoption certificate, foster care placement, or court order
- Marriage license
- Notification of Medicaid or CHIP denial
Note that all documents must be submitted within 30 days of picking a plan to apply for SEP.
Once you have chosen an affordable plan and gathered the correct documents, you can fill out the application quickly. Coverage starts the first day of the month after you pick your plan and documentation has been received.
Special Enrollment Period Frequently Asked Questions (FAQs)
To understand the caveats of the SEP, we are going to cover a few other common questions you may still have.
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Can I appeal the decision if I think I qualify for the SEP, but I was turned down?
Yes. According to the U.S. Centers for Medicare and Medicaid Services, you can appeal the decision of SEP qualification. You cannot appeal to change the information on your Marketplace application.
You can only apply to appeal the decision within 90 days after being notified of your ineligibility for the SEP. If you miss the appeal deadline, you can still attempt to appeal, but your appeal may or may not be heard. There is a location to describe why you missed the appeal period in Step 3 of the Appeals Form to receive a “good cause” extension.
If you need to receive coverage or keep coverage quickly but were denied eligibility for the SEP, you can ask for an expedited process on the appeal application. In some cases, you may be able to continue your coverage while the appeal process takes place.
Can I use the Special Enrollment Period to change plans if I am already on a Marketplace plan?
You are only able to change plans if you are no longer qualified for your current coverage. You cannot change plans if you want different coverage but still qualify for your current plan. The only way to change plans is to cancel your Marketplace coverage and purchase an independent insurance plan.
You can cancel your Health Insurance Marketplace plan at any time, and it will end the same day that you cancel the plan. You are also able to set the plan to be canceled on a certain date in the future. Do not cancel your coverage until you are on another plan.
You are also able to cancel coverage for only certain members covered by the Marketplace plan. You are also able to separately cancel a separate dental plan and keep the health insurance plan. To ensure that the coverage is canceled properly, you may want to call the Marketplace Call Center.
What are short-term insurance alternatives to plans through the Health Insurance Marketplace and Special Enrollment Period?
Other short-term insurance (or even long-term) plans are also available. Medicaid and CHIP are other federal alternatives if you qualify. You can apply for Medicaid and CHIP whether or not you qualify for the SEP. You can also purchase an independent health insurance plan.
If you liked the coverage under your previous employer-sponsored insurance program, you might be able to extend the coverage using the Consolidated Omnibus Budget Reconciliation Act (COBRA). This option is likely more expensive than the Healthcare Marketplace but may provide a more comprehensive coverage option.
In an emergency, you may want to consider catastrophic health insurance or other quicker options.
If you have missed the open enrollment period to obtain coverage from the Health Insurance Marketplace, you may still qualify for the Special Enrollment Period. Check to see if you qualify for the SEP and then apply for coverage.
If you do not qualify for or are searching for another coverage option, becoming a member of Mira’s care membership may be a good option for you. Mira offers basic coverage, including $99 urgent care visits, up to 80% off over-the-counter prescription cost, and same-day lab testing all for $45 per month. Sign up to get instant health benefits today.
Gavin is a 4th Year student at the University of Virginia, studying Medical Anthropology, Ethics, & Care as well as Environmental Science. He is passionate about providing healthcare resources and proper education in order to promote life and health for all.