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 With Open Enrollment closed for 2019 coverage, you may find some of your employees wondering what options they have, if any, for enrolling in health benefits for the year.  While they should be informed that there are no extensions to Open Enrollment for latecomers, they can find peace of mind knowing if they have experienced certain qualifying events leaving them in need of healthcare, they may be eligible for a Special Enrollment Period. 

A Special Enrollment Period (SEP) is the period outside of annual Open Enrollment when individuals can enroll in new healthcare benefits due to certain, specific qualifying events.  After experiencing a qualifying event, there is usually a 60-day window to enroll in healthcare coverage.  If an individual does not enroll during this window, he or she will have to wait until the next Open Enrollment period to enroll in healthcare coverage.

Qualifying Events for Special Enrollment Periods

Your employees may qualify for a Special Enrollment Period if they have experienced a change in household size, a change in residence, or a loss of eligible healthcare coverage.

Change in Household Size – If household size has changed due to one of the following circumstances, individuals may be eligible for healthcare enrollment through an SEP:

  • Having a baby or adopting a child
  • Getting married
  • Placing a child in foster care
  • Divorce or legal separation that causes a loss of health coverage
  • Death of a household member

Change in Residence – If one of your employees or anyone in his/her household has changed residence, giving them access to new Marketplace plans as a result, he or she may qualify for an SEP.  A change in residence includes:

  • Moving to a new home in a new zip code or county
  • Moving from the US to a foreign country or US Territory
  • If he/she is a student, moving to or from the place of attendance
  • If he/she is a seasonal worker, moving to or from the place he/she both lives and works
  • Moving to or from a shelter or other transitional housing

Loss of Eligible Coverage - If one of your employees or anyone in his/her household has lost eligible healthcare coverage in the last 60 days or expects to lose coverage within the next 60 days, he or she may qualify for an SEP.  Eligible healthcare coverage includes:

  • Coverage through an employer or a sponsor’s employer if he/she is a dependent.
  • Medicaid or CHIP
  • Medicare
  • Individual or group health plan coverage that ends during the year
  • Coverage under a parent’s health plan.  If an individual turn 26, making him/her ineligible receive health benefits through a parent’s health plan, he or she can qualify for a Special Enrollment Period. 

A few other circumstances which will allow them to qualify for a Special Enrollment Period include:

  • Losing eligibility for Medicaid or CHIP
  • Gaining membership in a federally recognized tribe or status as an Alaska Native Claims Settlement Act (ANCSA) Corporation shareholder
  • Becoming newly eligible for Marketplace coverage because he or she became a U.S. citizen
  • Leaving incarceration
  • Starting or ending service as an AmeriCorps State and National, VISTA, or NCCC member

After They Qualify, What Happens Next?

In order to enroll in a new health plan, inddiviuals must apply through the local healthcare marketplace.  After applying through the Marketplace, employees may be required to provide documents proving eligibility.  They will be prompted to either upload these documents online or mail copies before they can make their first premium payments and begin using the new coverage.  Healthcare coverage will begin after the first premium payment is made. 

Let Us Help!

With more than 20 years of experience in the industry, Berg Andonian is a team of healthcare brokers that takes pride in helping our clients find the right coverage options for their employees. If you have team members that may qualify for a Special Enrollment Period, we will gladly work with them team to determine thier eligibility and cverage options. Call us today to see what we can do for you!

Published January 9, 2019.