Health Insurance Marketplace
Special Enrollment Periods
What is a special enrollment period?
A Special Enrollment Period (SEP) is a period of time outside of open enrollment when consumers can enroll in marketplace coverage. A consumer can qualify for an SEP following certain life events or loss of Minimum Essential Coverage (MEC). (Note: MEC includes marketplace plans; individual market policies; job-based coverage; COBRA; health insurance through a government program such as Medicare, Medicaid, CHIP, or TRICARE; and certain other types of coverage that satisfy the ACA’s individual mandate.) If a consumer needs coverage but is not eligible for an SEP, she must wait until the next open enrollment period.
What types of Special Enrollment Periods are available?
A consumer may be eligible for an SEP in the following circumstances:
● losing minimum essential coverage;
● losing pregnancy related or medically needy Medicaid coverage that is not MEC;
● becoming a U.S. citizen, U.S. national or lawfully present individual;
● gaining or becoming a dependent (e.g., through marriage, birth, adoption, placement for adoption or in foster care, a child support order or other court order);
● ending a non-calendar year plan (even if able to renew);
● having one’s income rise above 100% Federal Poverty Level in a Medicaid non-expansion state thusbecoming newly eligible for Advanced Premium Tax Credits (APTCs);
● being a survive or of domestic violence or spousal abandonment;
● permanently moving to a different state or to a place within the same state where different Qualified Health Plans (QHPs) are available in the marketplace (includes being released from incarceration);
● becoming (or having one’s dependent become) newly eligible or ineligible for APTCs or having a change in Cost-Sharing Reduction (CSR) eligibility (if enrolled in a QHP);
● unintentionally, inadvertently, or erroneously being enrolled (or not enrolled) in a QHP due to the error, misrepresentation, misconduct or inaction of the marketplace, the Department of Health and Human Services (HHS) or its employees or agents, or by a non-marketplace entity providing enrollment assistance;
● having one’s QHP substantially violate a “material provision” of its contract;
● being a member of a federally recognized American Indian or Alaska Native tribe (can enroll in or change QHPs once per month); or
● meeting other “exceptional circumstances.”
What changes do not trigger a Special Enrollment Period?
While many changes in circumstance or life events can trigger SEPs, consumers should know that not all changes that they are required to report to the marketplace will allow them to enroll in or change plans. Some changes that do not trigger an SEP include:
● loss of MEC due to failure to pay premiums;
● voluntary COBRA cancellation;
● pregnancy (although pregnancy may lead to Medicaid eligibility and birth triggers an SEP);
● income changes, unless a consumer is currently enrolled in a QHP or has her income rise above 100% FPL in a Medicaid non-expansion state; and
● cancellation or termination of coverage due to a consumer’s fraud or “intentional misrepresentation of a material fact.”
What is the length of a Special Enrollment Period (SEP)?
Generally, an SEP lasts 60 days from the date of the triggering event. For example, if a consumer gives birth or gets married, the SEP is open for 60 days from the date of birth or the marriage. However, in certain situations consumers can apply for an SEP prior to the event triggering an SEP. For example, when a consumer knows that employer coverage is ending (due to leaving a job or the employer stopping coverage), he can request an SEP prior to the end of coverage. For Example: If coverage ends June 30th, he can apply through the marketplace as early as May 1st. The new marketplace coverage will not start until July 1st, but by beginning the process prior to termination of employer coverage the consumer can ensure continuity of coverage. In this example, the consumer still has 60 days after employer coverage ends to enroll in marketplace coverage through an SEP if he chooses not to begin the process prior to his employer coverage ending.
How Can Community Healthcare Center help?
Community Healthcare Center has Certified Application Counselors located at Community Healthcare Center and the Family Health Center. Our Certified Application Counselors provide free unbiased assistance and enrollment through the Health Insurance Marketplace.
To be eligible for the health coverage through the Marketplace, you:
- Must live in the United States
- Must be a U.S. citizen or national (or be lawfully present)
- Cannot be incarcerated
A measure of income level issued annually by the Department of Health and Human Services. Federal poverty levels (FPL) are used to determine your eligibility for certain programs and benefits.
2019 Federal Poverty Level
| Household/
Family size |
100% |
138% |
150% |
200% |
250% |
300% |
400% |
| 1 | $12, 490 | 17,236 | 18,735 | 24,980 | 31,225 | 37,470 | 49,960 |
| 2 | $16,910 | 23,336 | 25,365 | 33,820 | 42,275 | 50,730 | 67,640 |
| 3 | $21,330 | 29,435 | 31,995 | 42,660 | 53,325 | 63,990 | 85,320 |
| 4 | $25,750 | 35,535 | 38,625 | 51,500 | 64,375 | 77,250 | 103,000 |
| 5 | $30,170 | 41,635 | 45,255 | 60,340 | 75,425 | 90,510 | 120,680 |
| 6 | $34,590 | 47,734 | 51,885 | 69,180 | 86,475 | 103,770 | 138,360 |
| 7 | $39,010 | 53,834 | 58,515 | 78,020 | 94,525 | 117,030 | 156,040 |
Families/households with more than 7 persons, add $4,420 for each additional person.
At 100% poverty level you can start to receive subsides for lower premium cost and lower cost sharing. Income below poverty will most likely not receive subsidies.
400% is the maximum amount of income a family can have before they no longer qualify for subsidies. If a family makes more than 400% fpl, they can still enroll in the health Insurance Marketplace. But not eligible for tax subsides.
If you have other health coverage: Medicare Part A, B or C, Medicaid,CHIP, any job-based plan, and individual health plan, COBRA, retiree coverage, TRICARE, VA, or some other kind of health coverage you may not be eligible for subsidies.
HOW CAN I GET FREE IN-PERSON UNBIASED ASSISTANCE & ENROLLMENT?
Certified Application Counselors are available to offer FREE unbiased assistance and enrollment. We also have bilingual (Spanish speaking) Certified Application Counselors available by appointment. To schedule an appointment with Rhea, Rebecca or Cristal at Community Healthcare Center, please give them a call at (940) 766-6306.
Certified Application Counselors offices are located at:
Community Healthcare Center
200 Martin Luther King Jr. Blvd
Wichita Falls, Texas 76301
Family Health Center, A Service of Community Healthcare Center
1301 Third Street
Wichita Falls, Texas 76301
You can also apply online with the Health Insurance Marketplace at healthcare.gov or by calling 1-800-318-2596.
CLICK HERE to view and/or download the Authorization/Privacy Notice form regarding receiving free and unbiased assistance and enrollment with Certified Application Counselors at Community Healthcare Center. (Spanish version CLICK HERE)
