What are special enrollment periods?

If your health insurance plan isn’t working for you, you may not need to wait for open enrollment to change plans. Special enrollment periods (SEPs) are times when you are allowed to sign up for or change health coverage plans outside of the standard window.

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What is a special enrollment period?#what-is-a-special-enrollment-period

A special enrollment period (SEP) is a time outside of regular open enrollment when you can sign up for or change health insurance plans.

Most health insurance programs, including Marketplace plans, Medicare, and sometimes Medicaid managed care, have set enrollment windows. This is called “open enrollment,” or for Medicare it’s called the Annual Enrollment Period (AEP). During enrollment, people select their health insurance plan for the year by reviewing plan details like covered doctors, prescriptions, and services.

Usually once enrollment closes, you must keep the health insurance plan you selected until the next enrollment period.

Qualifying for a special enrollment period is the only way to change plans outside of that window.

Each health insurance program has its own rules for how special enrollment periods work, but the key similarity is that qualifying for an SEP requires that you experience certain life changes or “events.”

What events qualify for a special enrollment period?#what-events-qualify-for-a-special-enrollment-period

Special enrollment periods are meant to protect people who experience major life changes or other circumstances that affect their coverage. Most qualifying events for SEPs are circumstances that meaningfully change how your health insurance works or who it covers.

For example, a change of address is considered a “life event” for many health insurance programs. This is because moving could put you out of reasonable driving distance from your care team, and providers in your new location may not take your insurance.

Here’s a list of common events and situations that can activate special enrollment periods:

• Changing where you live: moving to a new home address or transitioning from an institution like a nursing facility or jail
• Losing health coverage: losing Medicaid eligibility or being laid off from your job and losing benefits
• Becoming eligible for a new opportunity for other health coverage: you or a spouse gaining new employment with new benefits, or turning 65 and being eligible for Medicare
• Experiencing family composition changes: getting married or divorced, having a baby or adopting, a death in the household
• Living in a disaster area: residing in an area where a federal, state, or local government entity declared a disaster or other emergency that prevented you from meeting open enrollment deadlines
• Updating inaccurate information: correcting when you were provided with incorrect or misrepresented information by your employer or a health insurance professional during open enrollment (in some cases)
• Having Medicare + Extra Help (low-income subsidy): qualifying for Extra Help, a subsidy to pay for Medicare prescription drug costs
• Being eligible for both Medicare and Medicaid (“dual eligibility”) (SEP-INT): individuals who qualify for both programs can use this special enrollment period to enroll in a Medicare plan that provides integrated care (INT), meaning the plan coordinates benefits across Medicare and Medicaid to simplify coverage.

What is SEP-INT?#what-is-sep-int

SEP-INT stands for the "integrated care special enrollment period." It helps people who have both Medicare and full Medicaid benefits (dual eligibility) enroll in Medicare plans that integrate Medicare and Medicaid coverage.

Integrated plans coordinate provider networks, cost sharing, and benefits across both programs so members can receive more seamless care.

During SEP-INT, eligible individuals may be able to enroll in or switch to an integrated Dual Eligible Special Needs Plan (D-SNP) that combines Medicare and Medicaid services. These plans usually require the Medicare plan and the person’s Medicaid Managed Care Organization (MCO) to be offered by the same insurance carrier. If needed, a person may be able to switch their Medicaid MCO to align with the integrated plan they wish to enroll in.

SEP-INT is generally available monthly for people who qualify as full-benefit dual eligible beneficiaries.

Other situations involving Medicaid or Extra Help may trigger different special enrollment periods, such as gaining or losing Medicaid or losing Extra Help. Because eligibility rules can vary, it’s a good idea to contact your health plan or Medicare to confirm which special enrollment periods you qualify for.

How does a special enrollment period work?#how-does-a-special-enrollment-period-work

Special enrollment periods can look very different depending on the program and your circumstances.

Generally, though, SEPs follow the same process:

• You request a special enrollment period and submit documented proof of your qualifying life event
• You are approved for an SEP window and are told how long you have to explore new plan options
• You review plans and select the one that’s best for you. Sometimes you can only change some, but not all, parts of your health coverage
• Your special enrollment window closes, and your new plan is active until the next open enrollment period

Plan changes may take effect as soon as the first day of the next month, though in some cases it can take longer. The exact start date depends on the type of coverage you are enrolling in. Each health insurance program has its own rules for how SEPs work.

How special enrollment periods work for Medicare#how-special-enrollment-periods-work-for-medicare

Medicare is a federal health insurance program for people aged 65 and older, and younger individuals with disabilities or specific medical conditions.

If you have Medicare, a special enrollment period can let you change your Medicare Advantage Plan, switch to Original Medicare (enroll in Part A hospital insurance and/or Part B medical insurance), and change your Medicare prescription coverage.

You will have anywhere from 60 days to 6 months to change your plan, depending on the reason. Once you select your new plan your coverage typically starts the month after you sign up. In some situations, you may be able to choose an earlier start date.

If you think you qualify, the best next step is to contact Social Security or Medicare, discuss your situation, and see what SEP you're eligible for.

How special enrollment periods work for Marketplace#how-special-enrollment-periods-work-for-marketplace

The Health Insurance Marketplace is the federal or state-run website ( Healthcare.gov) created under the Affordable Care Act where people can compare private health plans, see if they qualify for premium tax credits or cost savings, and enroll in coverage if they don’t have insurance through a job, Medicare, or Medicaid.

If you have health insurance through the Marketplace, you can check if you qualify for a special enrollment window on the Healthcare.gov website.

When you apply, you will be asked to confirm that your information is accurate and submit documents to prove your eligibility for the SEP. Healthcare.gov may redirect you to a state-run website; some states host their own Marketplace separate from the federal one.

How special enrollment periods work for Medicaid#how-special-enrollment-periods-work-for-medicaid

Special enrollment periods are less common in Medicaid than in Medicare or Marketplace coverage because Medicaid does not have an annual open enrollment period and you can apply for Medicaid at any time of year.

However, many states deliver Medicaid benefits through Managed Care Organizations (MCOs). An MCO is a private health insurance company that contracts with the state to provide your Medicaid benefits. Your MCO determines things like which doctors and hospitals are in-network and whether you need referrals.

Because Medicaid is state-run, SEP and plan change rules vary depending on where you live, but most states that use MCOs have special enrollment periods. States sometimes call their SEPs “good cause” exceptions, where they will allow you to change plans if you experience events, such as moving, losing access to your doctor, or having issues with care.

How special enrollment periods work for private health insurance?#how-special-enrollment-periods-work-for-private-health-insurance

If you have private health insurance directly through an employer or purchased outside of the Marketplace, special enrollment rules depend on the insurance company and the type of plan.

Employer-sponsored plans generally follow federal rules that allow changes after certain qualifying life events, and you typically have about 30 days to notify your employer and update your coverage. Individual plans purchased outside the Marketplace may not offer as many special enrollment options.

The best next step is to contact your employer's benefits team or insurance company directly to ask what plan changes are allowed and what documentation is required.