Updated September 2021

The Marketplace open enrollment period is the regular time each year when people can newly enroll in a qualified health plan or change to a different plan through the Marketplace. But certain events that occur during the year can trigger a special enrollment period (SEP), when a person may be able to newly enroll in a Marketplace plan or change to a different plan.

This SEP Reference Chart is a tool for those who are helping people enroll in health coverage through a special enrollment period. It focuses on the circumstances that trigger a SEP in the Marketplace, who can trigger a SEP, and the effective date of coverage once a health plan is selected.

Amid the COVID-19 pandemic, and the economic crisis that came about as a result, this abbreviated SEP Reference Chart provides a list of the most common SEPs used during this time.

People who missed their SEP window due to COVID-19 can still enroll in Marketplace coverage using the “FEMA SEP.” This fact sheet explains what the FEMA SEP is and how it works.

Additional Resources

Webinar: Special Enrollment Periods | View webinar

Minimum Essential Coverage Reference Chart | View chart

March 2021

On January 28th, 2021, the Centers for Medicare & Medicaid Services (CMS), the government agency that runs HealthCare.gov, determined that the COVID-19 emergency presents exceptional circumstances for people trying to access health insurance. Therefore, CMS has opened a Special Enrollment Period (SEP) from February 15 to August 15 for people to enroll in the coverage they need. This FAQ includes information about the new SEP, as well as tips on calculating income in uncertain times.

Additional Resources

Special Enrollment Period Reference Charts | View Charts

In this Health Reform: Beyond the Basics webinar presented on February 6, 2020, Sarah Lueck, Senior Policy Analyst, reviews the circumstances that trigger a special enrollment period and the timing of coverage effective dates for different triggering events. This webinar also covers changes and updates to the rules surrounding special enrollment periods.

↓ View Presentation Slides (PDF)

Watch the Webinar

Additional Resources

Reference Chart: Special Enrollment Periods

Beyond the Basics Webinar Series | View all webinars

Tools and Resources | View all tools and resources

Frequently Asked Questions | View FAQs

In this Health Reform: Beyond the Basics webinar presented on February 28, 2019, Sarah Lueck, Senior Policy Analyst, reviews the circumstances that trigger a special enrollment period and clarifies changes and updates to the rules surrounding special enrollment periods.

Presentation Slides

↓ View presentation slides (PDF) 

Watch the Webinar

Overview

Jump to video section, View slides 

Special enrollment period (SEP) review

• Timing
• Eligibility
• Coverage start date

Events that Trigger a Special Enrollment Period

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Loss of other qualifying coverage (video section, slides)

• Loss of minimum essential coverage
• Loss of pregnancy-related Medicaid coverage
• Loss of medically needy Medicaid coverage
• Expiration of a non-calendar year plan

Changes in household size (video section, slides)

• Marriage
• Birth / adoption / placement in foster care / court order

Changes in primary place of living (video section, slides)

• Permanent move

Changes in eligibility for financial help (video section, slides)

• Moving out of the Medicaid coverage gap
• Current employer plan no longer considered qualifying coverage
• Newly gaining eligible immigration status
• Release from incarceration
• American Indian and Alaska Native (AI/AN)
• Newly eligible or ineligible for premium tax credits
• Change in cost-sharing reduction eligibility

Enrollment or plan error (video section, slides)

• Error/misconduct/inaction
• Plan or benefit display error
• Health plan violation

Other circumstances (video section, slides)

• Being determined ineligible for Medicaid or CHIP
• Resolving a data-matching issue
• Survivors of domestic violence
• Exceptional circumstances

Events that do not trigger an SEP (video section, slides)

Restrictions on Plan Choice for Current Enrollees

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• Restrictions on Plan Selection
• SEPs exempt from restrictions on plan selection

Process for Accessing SEPs

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Reporting changes

• Accessing an SEP

SEP pre-enrollment verification (video section, slides)

• Process for verifying eligibility for SEP
• SEPs subject to pre-enrollment verification
• Documents that can be used to verify SEP eligibility

Additional Resources

Resources | View resources links

SEP Reference Chart | View reference chart

Beyond the Basics Webinar Series | View all webinars

Key Facts About Health Reform | View all key facts

Tools and Resources | View all tools and resources

In this Health Reform: Beyond the Basics webinar presented on September 27, 2018, Shelby Gonzales, Senior Policy Analyst, provides an explanation of the Healthcare.gov auto-renewal process for 2019 coverage and discusses both the process for plan auto-enrollment and redetermination of eligibility for the premium tax credit.

Presentation Slides

↓ View presentation slides (PDF) 

Watch the Webinar

Overview: Auto-Renewal Process and Notices

Jump to video section, View slides  

Two-step auto-renewal process

Renewal notices

• Marketplace open enrollment notices (MOEN)
• Insurer notices
• If insurer is no longer offering plans in the Marketplace

Redetermination of APTC

Jump to video section, View slides   

Auto-renewal process for APTC

• Eligible for redetermination of APTC
• Not eligible for redetermination of APTC
• Not eligible for auto-renewal (Medicare Anti-Duplication Provision) OR (member of an enrollment group has Medicare coverage)

APTC redetermination process for following coverage year

Auto-Enrollment for 2019 Plans

Jump to video section, View slides

Auto-enrollment process

• Option 1: Auto-enrolled into current plan
• Option 2: Auto-enrolled into new plan
• Option 3: Auto-enrolled into new plan with new insurer

Canceling auto-enrollment for 2019

Special enrollment period: 2018 plan discontinued

Tips for assisters

Q&A

Additional Resources

Resources | View resources links

Beyond the Basics Webinar Series | View all webinars

Key Facts About Health Reform | View all key facts

Tools and Resources | View all tools and resources

Frequently Asked Questions | View FAQs

↓ Read the final rule

↓ Read the guidance on hardship exemptions 

For an overview of the rule changes, see our paper, “Health Care Rule Changes Will Harm Consumers,” detailing how these changes will weaken benefit standards, likely harming people with pre-existing conditions; raising new barriers for people who want to enroll in health coverage; and reducing accountability for insurers and transparency for consumers.

Changes from the final rule and additional guidance include:

Altered rules for navigator programs.  Under the rule, marketplaces are permitted to have just one navigator entity serve the entire state. In addition, the rule allows navigators to not have a physical presence in the state they are paid to serve and no longer requires that one navigator group in a service area be a consumer-focused nonprofit organization.

New requirements for verification of income.  The rule requires individuals to verify their income if their attested income is above the poverty line but data sources suggest that income is below the poverty line. This will make it harder for eligible individuals with fluctuating poverty-level income to access much-needed financial help to afford coverage.

Expanded hardship exemption.  Effective immediately, new guidance expands the situations in which people can receive a hardship exemption to include people who:

• Show that a lack of choice when there is only one issuer in their area “precluded” them from obtaining coverage;
• Cannot buy an affordable plan that does not include abortion coverage, which is contrary to the individual’s beliefs;
• Have no qualified health plan in their area (a circumstance no marketplaces have ever experienced); or
• Experience personal circumstances that may qualify as a hardship, such as when available QHPs don’t cover needed specialty care.

New special enrollment period (SEP) for loss of pregnancy-related coverage provided through CHIP.  The rule adds an additional SEP for the loss of coverage provided through the Children’s Health Insurance Program (CHIP) “unborn child” option, which only covers pregnancy-related services and is not considered minimum essential coverage. This SEP will go into effect on June 18, 2018.

Removes requirement to provide adequate notice to those who fail to reconcile APTC.  People who receive APTC are required to file a tax return and reconcile the tax credit, or they risk losing financial assistance when they re-enroll. Current rules require that the Marketplace must first provide enrollees with information about failure to reconcile, giving them a chance to correct the record if they in fact reconciled or remedy the situation by filing a tax return, but the new rule removes that requirement to first send notice directly to the tax filer before discontinuing APTC.

Allows states and insurers to scale back benefits.  Beginning in 2020, the new rule changes the standards for how states create a benchmark plan to establish the minimum standard for the ten essential health benefits offered in that state and how insurers comply with them, opening up new ways for states and insurers to scale back coverage of services that are costly but critical to people with serious health needs.

There are additional changes in the rule including weakening the risk adjustment program by letting states shrink risk adjustment transfers by up to 50%, reduced transparency of insurance premium rates, and diminished standards for the “medical-loss ratio” requiring insurers to spend at least 80% of what they collect in premiums on medical care and improving healthcare quality. For more detailed information on the harmful changes in this rule, please see our paper, “Health Care Rule Changes Will Harm Consumers.”

Eligibility for a Special Enrollment Period

December 18, 2017

People enrolled in 2017 Marketplace plans that are discontinued for 2018 are eligible for the special enrollment period (SEP) for people losing minimum essential coverage. People eligible for the loss of coverage SEP have 60 days before or 60 days after the date their previous coverage ends to enroll in or change plans. For people whose 2017 plans are discontinued for 2018 that date is December 31, 2017.

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Who is eligible for this SEP?

Anyone whose 2017 Marketplace plan was discontinued for 2018 is eligible for an SEP, including:

• People enrolled in 2017 plans with insurers who are no longer offering coverage in their area.
• People whose 2017 plan is being discontinued but their insurer is still offering other plans in the Marketplace.

Everyone whose plan is discontinued is eligible for the SEP regardless of whether or not they are auto-enrolled into a new plan for 2018, or they actively select a new plan for 2018.

Everyone enrolled in a 2017 plan should have received a notice from their insurer detailing whether or not their 2017 plan would be offered in 2018. People with 2017 Marketplace coverage fall into one of the following categories:

• Their plan is no longer available and no other plans are available through that insurer. These consumers will get a notice from their issuers indicating that their plan is not being offered the following year. No information about a new plan will be in this notice, but the Marketplace will generally auto-enroll these individuals in a new plan with a new insurer if they don’t return to the Marketplace. The new plan will send information to the consumer about how to effectuate their coverage. These consumers are eligible for an SEP.
• Their plan is no longer available and the insurer will auto-enroll the person in a new plan. People will get a notice from their insurer indicating that their plan is not being offered the following year, and that they will be automatically enrolled in a new plan if they don’t return to the Marketplace and select a different plan. These consumers are eligible for an SEP.
• Their plan is available in 2018 and the insurer will auto-enroll the person into the same plan. People will get a notice detailing any changes to their plan for 2018. People can choose to remain enrolled in this plan for 2018 or choose a new plan during open enrollment. They are not eligible for an SEP — even if there are significant changes to the provider network, the cost sharing structure, or other features of their plan — because their coverage was not discontinued.

How do eligible consumers activate this SEP?

Consumers can activate this SEP online on HealthCare.gov or by calling the marketplace call center and indicating they have lost coverage just as they would if they lost other coverage from another source such as Medicaid or employer sponsored insurance. Two questions on the application ask if anyone in the household lost coverage in the past 60 days or if anyone is losing coverage in the next 60 days. Depending on whether it is before or after December 31, 2017, consumers should answer one of these questions affirmatively, and they should put December 31, 2017 as the date they are losing or have already lost coverage. This will trigger an SEP and allow consumers to enroll in a new plan. Consumers have until March 1, 2018 (60 days after December 31, 2017) to activate this SEP and choose a new plan. The coverage effective date of the new plan will be the first day of the month following plan selection. Eligible consumers should use this SEP as soon as possible to avoid potential gaps in coverage or being auto-enrolled in a plan that does not meet their needs.

When the discontinued plan was a Marketplace plan offered through HealthCare.gov, consumers should not have to submit documentation verifying the loss of coverage. However, if a person is asked to submit documentation, she can use the notice received from her insurer to prove that her coverage was discontinued.