Alyssa Lane
There are several life events that can qualify you for a Special Enrollment Period (SEP) to sign up for a Marketplace insurance plan outside of the Open Enrollment Period. These events include changes in your household, such as getting married, having a baby, or adopting a child, as well as losing your current health coverage, moving to a different location that impacts your insurance options, or turning 26 and aging out of your parents' insurance plan. If you experience any of these life events, it's important to act quickly and contact your insurer or the Marketplace to understand your coverage options and provide the necessary documentation to prove your qualifying life event.
| Characteristics | Values |
|---|---|
| Annual Open Enrollment Period | November 1 to January 15 |
| Special Enrollment Period | 60 days before or after a qualifying life event |
| Qualifying life events | Loss of health coverage, change in residence, change in household, becoming a U.S. citizen, turning 26 and aging out of parents' insurance, gaining membership in a federally recognized tribe, starting or ending service as an AmeriCorps member, government error, natural disaster |
| Documentation | Birth certificates, adoption records, marriage licenses, divorce paperwork, death certificates, rental agreements, deeds, mortgages, proof of address change, letter from a previous employer about health coverage termination |
| Income requirements | Individual income above $12,760 but below $51,040; family of 4 income above $26,200 but below $104,800 |
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What You'll Learn
Losing health insurance coverage
If you qualify for an SEP, you can apply for essential health insurance coverage 60 days before or after a qualifying life event. Your coverage can start the day of the event, even if you enroll in the plan up to 60 days afterward. If you have advance notice of your coverage loss, you can apply for the SEP up to 60 days in advance. After completing your application, you may be asked to send documents to confirm your eligibility for the SEP in your Marketplace Eligibility Notice. If you are asked to submit documentation, you will be allowed to select a plan, but your coverage won't start until you confirm your eligibility and make your first premium payment. Your health insurance coverage won't begin until you've paid your first premium.
If you've already signed up for COBRA coverage, you can switch to a Marketplace health plan. Marketplace plans take effect on the first day of the month after your job-based insurance ends. So, if you lose your insurance plan on March 7 and select a Marketplace plan by March 31, your new coverage can start on April 1. You may need proof that you lost health insurance through your job. When you apply for Marketplace coverage, you’ll receive an eligibility notice that will inform you if you need to submit documents to confirm your loss of coverage.
If you don't meet the qualifications for an SEP, you may still have other options for coverage. For example, you may be eligible to enroll in Medicaid, a government-run health insurance program that provides coverage for individuals and families who meet certain income and other eligibility requirements. You don't need to experience a qualifying life event to apply for and enroll in Medicaid.
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Changes in household composition
Changes in Family Size
Adding or removing members from your household can impact your eligibility for marketplace insurance. This includes having a baby, adopting a child, or placing a child for foster care. Getting married or divorced can also change your family size and insurance needs. In the case of divorce or legal separation, losing health insurance coverage may qualify you for an SEP.
Tax Dependents
When reporting changes in household composition, it is important to include any tax dependents you have. This can include parents, grandparents, foster children, or other adults you claim as dependents on your taxes. If you have relatives who live with you and rely on you for financial support, they may also be included in your household, but this is determined on a case-by-case basis.
Income Changes
Changes in household income can significantly impact your eligibility for marketplace insurance and the amount of subsidy you may receive. It is important to update your information with the health insurance marketplace when your income changes during the year. If your income increases, you may need to pay back some of your subsidy through your income tax return. On the other hand, if your income decreases, you may be eligible for a larger subsidy.
To qualify for savings on the Marketplace, your income must fall within certain thresholds. For example, an individual with an income above $12,760 but below $51,040 may qualify for savings, while a family of four with an income above $26,200 but below $104,800 would typically qualify for savings.
It is important to note that you may be required to provide documentation to support any changes in your household composition, such as birth certificates, adoption records, marriage licenses, or divorce paperwork.
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Changes in residence
Moving to a new location can impact your insurance options and is considered a qualifying life event. This could include moving to a different zip code, county, or state that changes your health plan area. You may qualify for a Special Enrollment Period (SEP) if you move to a new state or country and need to enroll in a new plan.
If you are moving, it is important to report your change of address and update your application. You can do this by logging into your Marketplace account and selecting your name and "My Profile" to edit your address. It is very important to report moves out of state immediately so you can enroll in a new plan without a break in coverage and avoid paying for coverage that doesn't apply in your new state. When you move out of state, you will need to start a new Marketplace application and enroll in a plan in your new state.
If you know you will be moving soon, it is a good idea to contact your insurer or the Marketplace in advance to avoid a coverage gap. You may be required to provide documentation of your move, such as new rental agreements, deeds, or mortgages, to show that you have moved into a new health insurance plan area.
In addition to moving, other qualifying life events that may allow you to sign up for marketplace insurance include losing health coverage, changes in your household, getting married, having a baby, adopting a child, or a change in your income.
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Changes in income
Income Changes and Special Enrollment Periods: Income changes can qualify you for a Special Enrollment Period (SEP), allowing you to adjust your health insurance plan outside of the regular Open Enrollment period. If your income decreases, you may become eligible for savings on a Marketplace plan or even qualify for Medicaid. On the other hand, if your income increases, you may no longer be eligible for certain subsidies or savings, and you should report this change to avoid future repayment issues.
Documentation and Proof: When applying for an SEP due to income changes, you will likely need to provide documentation to prove your qualifying life event. This could include tax returns, pay stubs, or other financial records. It's important to be prepared to submit these documents within the required timeframe, which is typically within 30 days of reporting the qualifying life event.
Income Thresholds and Savings: Marketplace insurance plans often offer savings based on income thresholds. For example, if your income as an individual is below $51,040, you may qualify for savings on a Marketplace plan. These thresholds vary depending on factors such as the number of family members and the state you live in. You can use online tools, such as subsidy calculators, to determine your potential eligibility for savings.
Medicaid Eligibility: If your income decreases significantly, you may become eligible for Medicaid, a government-run health insurance program for low-income individuals and families. Each state has its own income eligibility requirements for Medicaid, so be sure to check the guidelines for your specific state. Losing Medicaid coverage due to increased income may also qualify you for an SEP, allowing you to explore other insurance options.
Timing and Coverage Gaps: It is important to act promptly when reporting income changes and applying for an SEP to avoid gaps in your health insurance coverage. You typically have 60 days from the date of the qualifying life event to report the change and adjust your health plan. Once reported, changes can take effect quickly, often starting on the first day of the following month.
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Becoming a U.S. citizen
Becoming a US citizen is a significant life event that can impact your health insurance options and eligibility. Here is some information on what you need to know about becoming a US citizen and how it relates to marketplace insurance:
First and foremost, US citizens and lawfully present non-citizens in the US are eligible to enrol in Marketplace health insurance plans. These plans are available through HealthCare.gov or other brokers, and they cover health care provided by doctors, hospitals, and other providers within the US. It is important to note that if you have Medicare coverage, you cannot enrol in a Marketplace plan.
If you are in the process of becoming a US citizen, there are a few things to keep in mind regarding your health insurance options:
- Special Enrollment Period (SEP): Becoming a US citizen qualifies you for a Special Enrollment Period, which is a time outside the yearly Open Enrollment Period when you can sign up for health insurance. During this period, you can enrol in or change your Marketplace plan. You must contact the Marketplace Call Center to complete your enrolment, as it cannot be done online.
- Documentation: When applying for health insurance during the Special Enrollment Period, you may be required to provide documentation to prove your citizenship status. This could include naturalization certificates, passports, or other relevant documents.
- Income and Residency Considerations: Your income and residency status will impact your eligibility for different health insurance plans. If your income is below a certain threshold, you may qualify for savings on your Marketplace plan or be eligible for government-run programs such as Medicaid. Additionally, if you are moving to the US from a foreign country or US territory, your residence change may also qualify you for an SEP.
- Timing: It is important to be mindful of timing when enrolling in health insurance after becoming a US citizen. You typically have 60 days before or after the qualifying life event (in this case, becoming a US citizen) to apply for coverage during the Special Enrollment Period.
In summary, becoming a US citizen is a qualifying life event that allows you to sign up for marketplace insurance outside of the Open Enrollment Period. Remember to contact the Marketplace and provide any necessary documentation to confirm your citizenship status and complete your enrolment.
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Frequently asked questions
A qualifying life event is a change in your circumstances that allows you to purchase a health plan outside of the Open Enrollment Period.
Qualifying life events include, but are not limited to, getting married, having a baby, adopting a child, losing health coverage, moving, and gaining membership in a federally recognized tribe.
If you experience a qualifying life event, contact your insurer or the Marketplace as soon as possible to understand your coverage options and what documents you need to provide. You typically have 60 days from the date of the qualifying life event to report it and change your health plan.
Depending on the event, you may need to provide documents such as birth certificates, adoption records, marriage licenses, divorce paperwork, death certificates, new rental agreements, deeds, or proof of address change.
If you do not meet the qualifications for a Special Enrollment Period, you may still have options for coverage. For example, you may be eligible to enroll in Medicaid, which is a government-run health insurance program that provides coverage for individuals and families who meet certain income and other eligibility requirements.
