10 Ways to Qualify for a Special Enrollment Period

by Karen Ball | Uncategorized

With the onset of the Affordable Care Act (aka Obamacare), enrolling in a health plan has been restricted to a particular time frame called Open Enrollment.  This generally happens toward the end of the calendar year, with new plans beginning January 1^st of the following year.  But what do you do if something changes in your life and you need new health insurance mid-year?  You may or may not be able to get it.  Here are the 10 categories that will afford you a Special Enrollment Period (SEP) in which to enroll in a new health plan:

1. Losing other qualifying coverage:
   • You were on Medi-Cal and no longer qualify
   • If you newly qualify for Medi-Cal, you can enroll at any time.
   • You had employer-sponsored coverage and lost/quit your job
   • You had COBRA and exhausted those benefits.  Dropping COBRA because it is too expensive DOES NOT qualify.  However, you do not have to accept COBRA if it is offered to you.
   • You no longer qualify for a student health plan through a university
   • You turn 26 years old and need to come off your parent’s plan
   • You turn 19 and no longer qualify for a ‘child only’ plan
   • You no longer qualify for military coverage
2. Changes in household size
   • Marriage, divorce, legal separation
   • Birth or adoption of a child
   • Death
   • Any other situation where you lose a dependent or your status as a dependent
3. Changes in residence
   • Permanently moved from out of state
   • Permanently moved within the state to a location that offers at least one new Covered CA plan to which you previously did not have access
   • Permanently moved within the state and your current plan is not offered in your new location
4. Changes in eligibility for financial help
   • Gain or lose status with Medi-Cal
   • Lose your ‘share of cost’ with Medi-Cal by reaching your share of cost
5. Defined types of errors made by the Marketplace, Plans, or Agents
   • You were given misinformation during the enrollment process
   • There were technical errors with the software during your enrollment
   • There were errors in the processing of your eligibility determination
6. Release from jail or prison
7. Gained Citizenship or Lawful Presence
8. Member of a Federally recognized American Indian or Alaska Native tribe
   • Members have an open Special Enrollment Period and can enroll at any time
   • Members can change plans once every month
9. Your provider (doctor) left the plan’s network AND you have one of the following:
   • Pregnancy
   • Terminal Illness
   • Acute Condition
   • Serious Chronic Condition
   • Care of a child between the ages of 0 – 36 months
   • Surgery or Procedure scheduled within 180 days of the provider’s change
10. All Other Reasons
    • Natural disaster (fire, flood, hurricane, etc.)
    • You had a medical emergency that precluded you from enrolling during open enrollment
    • You are a victim of domestic violence or spousal abandonment
    • You have a court order to provide insurance for a dependent, even if you will not be claiming that dependent on your tax return.

It’s a long list to remember.  So, if you just remember that the circumstances must be beyond your control, you will probably find that you qualify for a Special Enrollment Period.  But be mindful:  your SEP is only 60 days long and starts the day your change happens.  If you miss your 60-day window, you will have to wait for the next Open Enrollment Period to receive a plan beginning the next year.

Unfortunately, California no longer allows interim, or short-term, plans to carry you through.  Your only options are the Marketplace (Covered CA) or purchasing something directly with the insurance company.  A health insurance broker (like Pronoeo Insurance Agency) can guide you.