Enrolling in ACA coverage outside Open Enrollment
Period
Dates
Notes
Open Enrollment (FFM)
Nov 1 - Jan 15
Standard enrollment window
Special Enrollment Period (SEP)
Anytime with QLE
Requires verification
19 recognized categories including:
Loss of existing coverage (job-based, Medicaid, etc.)
Loss of Medicaid/CHIP
Loss of Minimum Essential Coverage (MEC)
Household size changes (marriage, birth, adoption)
Household income changes
Permanent address change
Subsidy eligibility changes
Newly gaining eligible immigration status
Released from incarceration
Is or becomes a member of a federally-recognized Native American tribe or an Alaska Native Claims Settlement Act Corporation Shareholder
If you are enrolling a consumer because of a FEMA disaster, you will need to call the Marketplace (1-800-318-2596) to complete the enrollment.
For annual income up to 150% FPL, CMS generates low-income SEP automatically when eligibility application is submitted. If a consumer experiences a change in income that makes a member eligible or ineligible for APTC/CSR, the Financial Change SEP is also detected by CMS when eligibility application is submitted.
Automatic detection in JET EDE
Who is eligible for this SEP?:
To qualify for the new SEP, applicant must:
Be eligible for an APTC based on the normal eligibility rules
Have an annual projected income that is at or below 150% FPL
Medicaid expansion states have Medicaid covered until 138% FPL; this means low-income SEP will only be available between 138% and 150%.
Non-Medicaid expansion (12) states, have Medicaid covered until 100% FPL; this means low-income SEP will be available between 100% and 150%.
Coverage starts: 1st of next month
Documentation required for verification (DMI/SVI)
DMI: 90 days to submit (proof of income)
SVI: 30 days to submit (proof of QLE)
Plan changes may reset deductibles/OOP max
No "double-dipping" - can't combine with employer coverage