Special Enrollment Periods for complex issues

Outside the Open Enrollment Period, you can enroll in a private health plan through the Marketplace only if you qualify for a Special Enrollment Period.

You can qualify for a Special Enrollment Period if either of the following applies to you:

Other complicated cases that may qualify you for a Special Enrollment Period

Below are cases and examples that may also qualify you for a Special Enrollment Period:

Exceptional circumstance

You faced a serious medical condition or natural disaster that kept you from enrolling. For example:

  • An unexpected hospitalization or temporary cognitive disability
  • A natural disaster, such as an earthquake, massive flooding, or hurricane

Enrollment or plan information display errors

  • Misinformation, misrepresentation, misconduct, or inaction of someone working in an official capacity to help you enroll (like an insurance company, navigator, certified application counselor, or agent or broker) kept you from:
    • Enrolling in a plan
    • Enrolling in the right plan
    • Getting the premium tax credit or cost-sharing reduction you were eligible for
  • A technical error occurred when you applied on HealthCare.gov -- you probably saw an error message when completing your application – that prevented:
    • You from enrolling in a plan, or
    • Your health insurance company from receiving your enrollment information
  • The wrong plan data was displayed on HealthCare.gov at the time that you selected your health plan, such as benefit or cost-sharing information.

Live in a state that hasn’t expanded Medicaid and become newly eligible for help paying for your coverage

You live in a state that hasn’t expanded Medicaid and weren’t eligible for Medicaid or advance payments of the premium tax credit (APTC) when you first applied because your income was too low. But in the last 60 days, you had a change in household income that makes you newly eligible for premium tax credits.

Being determined ineligible for Medicaid or CHIP

You applied for Medicaid or CHIP during the Marketplace Open Enrollment Period and your state Medicaid or CHIP agency determined that you weren’t eligible for Medicaid or CHIP after Open Enrollment ended. You may qualify for a Special Enrollment Period regardless of whether you applied through:

  • The Marketplace and your information was sent to your state Medicaid or CHIP agency, or
  • Your state Medicaid or CHIP agency directly

Gain or become a dependent due to a child support or other court order

You gained a new dependent or became a dependent of someone else due to a court order. Your coverage would start the effective date of the court order – even if you enroll in the plan up to 60 days afterward.

Experience domestic abuse/violence or spousal abandonment

You're a survivor of domestic abuse/violence or spousal abandonment and want to enroll in your own health plan separate from your abuser or abandoner. You can enroll by contacting the Marketplace Call Center. Your dependents may be eligible too.

If you’re married to your abuser/abandoner, you can answer on your Marketplace application that you’re unmarried, without fear of penalty for mis-stating your marital status. You then become eligible for a premium tax credit and other savings on a Marketplace plan, if you qualify based on your income.

If you qualify for this SEP, you'll have 60 days to enroll in a Marketplace plan.

Prevail on Appeal

You believe you received an incorrect eligibility determination or an incorrect coverage effective date and file an appeal with the Marketplace. If the ruling goes in your favor, you’ll be given the option to enroll in or change plans either retroactively or prospectively.

If you think you qualify for a Special Enrollment Period

If you think you qualify for a Special Enrollment Period, contact the Marketplace Call Center at 1-800-318-2596 (TTY: 1-855-889-4325)

The representative will ask for information about your situation to determine if your circumstances qualify you for a Special Enrollment Period. The representative will help you apply and enroll in coverage.

If you’re already enrolled in a plan and you get a Special Enrollment Period, you can stay in your current plan in most cases, or you can switch plans. In some limited cases, you may qualify for an earlier effective date of coverage. Remember, you must make the first premium payment before your coverage becomes effective.

Filing an appeal

If your request for a Special Enrollment Period is denied, you can file an appeal. If the denial is found incorrect, you can get coverage back to the date your Special Enrollment Period was denied.

How to file an appeal:

  • Select your state’s appeal form, download it, and fill it out
  • Mail your appeal to:

    Health Insurance Marketplace
    Attn: Appeals
    465 Industrial Blvd.
    London, KY 40750-0061

When possible, include a copy of any eligibility determination notice or other official notice you received. This isn’t required, but will help us process your appeal.

When mailing the appeal request to the Health Insurance Marketplace, be sure to include the last 4 digits of the London, KY ZIP code (40750-0061). This will help your appeal arrive faster.