Health Insurance Marketplace Facts: Special Enrollment Periods
If you subscribe to our newsletter, you may recall reading about open enrollment for individual health insurance through the Health Insurance Marketplace. We encouraged you to start doing your research now so that you’re ready to choose your plan as soon as open enrollment starts on November 1. In this Health Insurance Marketplace fact sheet, we discuss why you may need a Special Enrollment Period and how to get it.
Health Insurance Marketplace Facts
Signing up for individual health insurance early means that you won’t have a gap in coverage. Open enrollment for much of the country is two and a half months (2025 update: this will be decreasing). But there are a variety of reasons why people skip it — like if you currently have health insurance through your employer.
If you don’t sign up for insurance before the deadline in your state and lose your coverage later on, or if you do sign up but then involuntarily lose your plan, you can still get insurance. You can sign up for individual health insurance through the Marketplace outside of open enrollment. This is known as a Special Enrollment Period, or SEP.
In the event you lose your group health insurance, we put together this special enrollment period fact sheet for the Health Insurance Marketplace. Using this guide and getting new insurance means you won’t have to go very long without health insurance coverage.
Get Help Signing Up for Health Insurance
Open enrollment is just around the corner. Don’t go it alone if you have questions. Work with a Navigator or certified enrollment counselor to help you with your Marketplace application. See our blog post, “How to Get Free Help Enrolling in Individual Health Insurance.”
What are Special Enrollment Periods
At DHC, it’s our goal to help people get the most from their health insurance. So we’d be remiss not to explain how SEPs work. In this article, we lay out various reasons why folks qualify to enroll in health insurance before or after open enrollment.
According to HealthInsurance.org, millions of people are unaware they qualify for a SEP to sign up for individual insurance outside of open enrollment. That’s too bad because it means that folks go without health coverage when they don’t have to.
Special Enrollment Period Qualifications
Here are the circumstances that may qualify you for a special enrollment period. These SEPs apply to individuals and members of their household.
Involuntary loss of coverage
If you lose qualifying health coverage, you may be able to get individual health insurance through a SEP. For example, if you have a full-time job that provides health benefits, then you don’t need sign up for insurance during open enrollment. Then, if you lose your job later in the year, you may think you need to wait for open enrollment to come back around. The truth is, you don’t. You can apply for a SEP.
Another way to involuntarily lose health insurance is by turning 26 years old. That’s the age at which young adults can no longer get coverage through their parents’ health insurance plan.
To enroll in health insurance during a SEP, you have 60 days before or after you lose qualifying insurance to report it.
Change in household size
If your household grows or decreases in size, you can enroll in individual health insurance through a SEP. Here are some events that could change the size of your household:
- You got married
- You have a baby
- You adopt a child
- A minor from your household is placed into foster care
- You lost health insurance due to a divorce or legal separation
- If someone in your household dies and it results in you losing health insurance, you may qualify for a SEP.
Primary place of residency changed
Moving to a new zip code or county qualifies you for a SEP since the local health plans will be different — that includes those who were living in a shelter or transitional housing. When a college student moves to or away from school or a seasonal worker moves to or away from their place of employment, they can qualify for a SEP.
Your eligibility for Marketplace coverage changed
You qualify for a SEP if you become newly eligible for insurance or newly eligible for assistance paying for a plan.
Also, individuals who become American citizens or otherwise achieve lawful status in the country may qualify for a SEP. Release from prison, jail, and detention may also qualify you for a special enrollment period.
Enrollment error
If you worked with a navigator or certified application counselor and they made a mistake on your application, you can apply for a SEP. If misconduct resulted in you being enrolled in the wrong plan, or not enrolled at all, you can ask for a SEP. The same goes if you enrolled in the Marketplace through HealthCare.gov and you were presented with incorrect plan data or cost-sharing information.
Other reasons for SEP eligibility
Here are even more reasons why you may qualify for a SEP:
- You determine your income is below 150% of the federal poverty level and you qualify for premium tax credits.
- Victims of domestic abuse and/or abandonment can enroll in a health plan separate from their abuser.
- If you were asked to confirm Marketplace eligibility after your coverage ended, and it resulted in missing the deadline for coverage, you may qualify for a SEP.
- Demonstrating that an exceptional circumstance prevented you from signing up for health insurance could qualify for a SEP. This can happen following a natural disaster.
Learn more about Special Enrollment Periods at Healthcare.gov and determine your next steps.
What to do if you qualify for a SEP
If you’re ready to demonstrate your SEP eligibility, just go to HealthCare.gov/screener. You can also call 1-800-318-2596 (or 1-855-889-4325 for TTY users). You’ll be asked to answer a few questions, including those that determine eligibility for Medicaid and the Children’s Health Insurance Program (CHIP).
