Special Enrollment Period: Who Quialifies and Why

Special Enrollment Period

If you are an individual who lacks insurance or recently suffered from a loss of coverage, the Coronavirus Pandemic will weigh heavily on your mind. Without individual health insurance, facing the risk of needing unexpected prescription drugs or hospitalization will create an enormous bill without the proper health coverage for your needs.

In the insurance world, there are protections against these unexpected losses of coverage. They are known as Special Enrollment Periods. Should you meet the requirements, special enrollment offers a re-opening of the insurance marketplace for a limited time. Thus, you are able to enroll in a plan without going uninsured.

As such, we have complied an article outlining some of the most common special enrollment periods you will encounter in addition to the life events you must meet to satisfy re-enrollment requirements.

What is a Special Enrollment Period?

When applying for insurance, individuals must apply during a specific period of time called the open enrollment period. In times of national crisis, or after certain qualifying events, these enrollment periods can either be extended or reopened all together. This allows for individuals who are otherwise not insured, or not ensured properly, to apply for a plan with comprehensive coverage.

These are known as special enrollment periods (SEP) as they give individuals special access to a new enrollment window. You may qualify for an SEP no matter what your previous insurance coverage was. As such, whether you were formerly enrolled in a prescription drug plan, medicare part program, or insurance from your employer, you can still qualify to re-enroll outside of the normal period.

Qualifying for a Special Enrollment Period as an Individual

Not everyone qualifies for a special enrollment period nor are they always within the appropriate window of time to enroll. Generally, you are eligible to for special enrollment under when the following circumstances are met:

  • Marriage that can result in a change of coverage
  • Death of another member on the same marketplace plan
  • Adopted a child
  • Lost health coverage after a divorce or legal separation
  • Lost health coverage due to job loss, being furloughed, or a reduction of working hours

For an in-depth explanation on these circumstances in addition to more government resources, please see the following linke at healthcare.gov. 

Special Enrollment Period for Group Health Insurance 

Special enrollment periods for group health works in two parts: the first is on behalf of the employee sponsor, the second is on behalf of the individual seeking coverage.

For individuals, the special enrollment triggers remain the same as those listed above.

For small businesses with 2-50 full time employees, there is a time each year to take advantage of a special enrollment period for you and your staff. This period aims to make it easier and more affordable for small companies to offer health benefits. The two main advantages of this particular SEP being:

  • Your business will not be required to contribute to insurance premiums 
  • Only one employee is needed to establish the group plan

Special Enrollment Period: Medicare

For those working at an employer after you turn 65, you were likely given a choice to either maintain your employer coverage or choose to defer your enrollment in part (or all) of your medicare benefits. For some, this causes them to miss the Initial enrollment period– a span of time that begins 3 months before your birth month, lasts through your birth month, and finally remains open for 3 additional months after.

If you miss this initial time to enroll, there is still time to get health coverage through medicare up to and including prescription coverage and the Medicare advantage plan.

Special enrollment periods for medicare are calculated based on slightly different qualifying standards than those for group or individual health plans. There are also different requirements for each of the different Medicare “Parts.”

For Parts A and B, special enrollment qualifications include:

  • When you are still covered under a health insurance plan from you or your spouse’s employment 
  • The 8 months following a loss in coverage

For Parts C and D, special enrollment qualifications include:

  • Must concurrently enroll in Parts A and B
  • The 63 days following termination of employment or loss of employee-sponsored coverage

Finally, there are a few more qualifying events that can trigger a SEP for Part D. Those additions are:

  • Moving away from the area served by your current plan or your current plan no longer servicing your location
  • Change in living situation including entering, leaving, or moving ruesing homes
  • You receive Extra Help for your prescriptions

Calling an Insurance Expert

When looking for insurance plans after experiencing a lapse in coverage or uncertain employment, trying to get the information you need from the internet can be confusing. Especially when looking at potential exceptions to the open enrollment process, your individual situation makes a difference between whether you qualify to re-enter the marketplace or will face a penalty. This is why speaking to an insurance expert is the best way to ensure you get the best possible coverage available to you.

At the Gebhardt Insurance Group, we offer a variety of coverage from a host of major insurance carriers with an experienced staff that can help you determine whether you can take advantage of special enrollment periods. Give us at call at 520-836-3244 to get a quote and make an appointment to take the final steps in insuring your business.

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Steve Gebhardt

Gebhardt Insurance Group was honored by AAA Insurance for being the top New Policy Agency in Arizona for 2013 and achieving the "Emerald Achievement Award."
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