What is a Special Enrollment Period

Health coverage: qualifying for a special enrollment period

During these uncertain times, a lot can change fast. If you have lost or are losing your health insurance coverage because of a change in your employment status, you may qualify for a special enrollment period (SEP).

What is an SEP?

Through the Affordable Care Act, you may be eligible for an SEP if you experience a qualifying life event. This means you and your family can enroll or change your health insurance outside of the open enrollment period.

Typically, the open enrollment period for individual health insurance occurs from November 1 to December 15, with an effective date of January the following year. Once open enrollment ends, you are unable to enroll in a new health plan until the next open enrollment period.

If you qualify for an SEP, you have 60 days from the day of your qualifying life event to change or enroll in another health plan. If you fail to take action within 60 days, you are without coverage until the next open enrollment period.

What are qualifying life events?

Many life events can qualify you for an SEP.

These include: 

  • Adopting a child or having a baby
  • Getting married
  • Losing your health insurance coverage
  • Moving

Some life events, such as an unexpected illness or medical injury, do not qualify.

What if I choose to continue coverage through COBRA?

Some people choose to enroll in COBRA (Consolidated Omnibus Budget Reconciliation Act) coverage. This is a health insurance option that allows you and your dependents, if you are eligible through your employer, to temporarily continue your employer-sponsored health insurance coverage due to unemployment, furlough (temporary leave of employment) or a reduction in work hours.

The value of electing COBRA is a smooth transition of remaining on the current employer-sponsored health plan without any gaps in coverage or loss of cost sharing applied to the deductible and out-of-pocket maximum. However, once COBRA is elected, you no longer have an SEP to elect an individual health plan until the next open enrollment period.

How do I choose an individual health plan?

Once you know you qualify for an SEP, it is time to consider your coverage options. Careful thought should be taken when considering a health plan. Evaluate the coverage options that support the needs of you and your family.

The federal Health Insurance Marketplace at healthcare.gov is a great option if you may qualify for financial assistance. See if you qualify, as this will help lower your monthly premiums and potentially reduce your out-of-pocket costs. The federal Health Insurance Marketplace does count loss of coverage as a qualifying life event for an SEP, but documentation proving loss of employer coverage is required.

Should you or your dependents qualify for Medicaid or the Children’s Health Insurance Program (CHIP), you can enroll in both programs year round.

If you would rather select coverage through a local provider-owned health plan, Sanford Health Plan offers multiple options to meet your needs, lifestyle and budget, with: 

  • Affordable monthly premiums
  • $0 preventive care and screenings
  • $0 virtual care 24/7
  • Savings on dental, vision and hearing services
  • A team dedicated to your whole health

Are you an employer? Download the Sanford Health Plan Employer Guide for resources and support to help you maintain coverage for your employees or to assist your employees in finding covered due to an SEP.

What are my health insurance options if/when I get laid off?

If you experience a loss of health insurance coverage due to a layoff, it is important to contact a local benefits expert and review your options. Your options may vary depending upon your situation. Sanford Health Plan is here to help. We can connect you with a local licensed agent to review your options – which may include COBRA through your employer, Individual coverage, or possibly Medicaid or Medicaid Expansion depending on the state you live in.

What should I do right away?

Don’t wait—start investigating right away. You might have access to employer-based coverage through a family member’s plan. If you are younger than 26, the Affordable Care Act allows you to be covered under your parent’s insurance plan. In addition, if your spouse has employer-based health insurance, see if you can be enrolled in their plan.

What if I can’t get employer-based coverage through a family member’s plan?

Consider individual and family coverage through the Marketplace – or directly through Sanford Health Plan. The loss of employer coverage most likely qualifies you for a Special Enrollment Period outside of the typical Open Enrolment timeframe with any insurance carrier you choose. Sanford Health Plan can help you navigate your options and connect you with a licensed agent.

Is Medicaid or Medicaid Expansion an option?

Depending on the state you live in, you may want to check your Medicaid or Medicaid Expansion eligibility — even if you don’t think you qualify. This may not be your first instinct if you’re used to having job-based coverage, but it’s worth looking into. Medicaid offers free or low-cost care and comprehensive benefits. Coverage can take retroactive effect as far back as three months, as long as you were eligible during that retroactive period.

My employer offered me something called COBRA – should I use this?

COBRA, short for the Consolidated Omnibus Budget Reconciliation Act, generally lets workers at companies of 20 or more employees extend their health coverage for up to 18 months after losing their jobs. It is important to note that you would now be responsible for paying both your portion and your employer’s portion of the premium — plus a 2% administrative fee. Electing to use COBRA allows you to keep your accumulators for deductible/OPM cost-share. It is an important to consider this option.

I’m seeing a lot of short-term plans – is this a good idea?

While the low cost of these plans can be appealing— understanding this type of plan and exactly what it will cover or not cover is important. Short-term plans often will not offer coverage to people based on preexisting conditions and offer relatively limited benefits. They are often meant to provide catastrophic coverage during a short time-frame. We would recommend working with a licensed agent to review and understand how any short-term plan you are considering would work.

What if I’m over the age of 65 and get laid off?

Individuals over age 65 will likely transition to a Medicare plan. If they’ve not been enrolled in Medicare Part A and Part B, there’s an employer form that documents they’ve been on the group health plan after age 65: the form CMS-L564. It’s important employers ensure individuals over 65 receive this form quickly because that will facilitate their enrollment into Medicare as quickly as possible.

Qualify for an SEP? Call the Sanford Health Plan coverage hotline at (888) 535-4831 to learn more about your coverage options with Sanford Health Plan.