The annual Open Enrollment period ended December 15th, 2017. After the open enrollment period only eligible individuals can enroll in an individual health insurance plan if he or she qualifies for a Special Enrollment Period (SEP). Special Enrollment Period is a time outside the yearly Open Enrollment Period when you are able to sign up for health insurance. If you qualify for an SEP, you usually have up to 60 days following the event to enroll in a plan. You can qualify for SEP if you’ve had certain life events including: loss of minimum essential coverage, dependent attained age 26 or 31 years, marriage, birth, adoption, foster care, child support, you move, The Health Insurance Marketplace changed subsidy determination, NJ FamilyCare/Medicaid denial, and Domestic abuse or spousal abandonment. Along with these events, individuals must show proof that these events occurred.
It is important that individuals know if they qualify for the special enrollment period and if they do qualify, that they provide proof of the triggering event and proof of the date of the event. If an individual loses minimum essential coverage including: individual, group or government sponsored plans they need to apply 60 days before or 60 days after the event. Below, there will be explanations of events that qualify an individual for special enrollment and what documentation will be needed to confirm the event.
1. Loss of minimum essential coverage: individual, group, or government-sponsored plan:
Losing coverage due to a life event including: legal separation, divorce, death of and employee or policyholder: They will need separation document, divorce paper, or death certificate and dates on the documents.
Loss of group insurance:
Termination of employment: The acceptable documentation is a letter from the employer on employer’s letterhead stating coverage ended or will end due to termination of employment or official documentation from the unemployment agency along with reason of termination
Reduction in work hours: The acceptable documentation is a letter from employer on employer’s letterhead stating coverage ended or will end due to a reduction in work hours, or official documentation from the unemployment agency along with reason for termination, or copy of pay stubs of both current and previous hours showing health deductions were elimated along with a termination letter showing that a reduction in work hours cause the individual to lose coverage.
Your employer stopped contributing toward the cost of you and your dependent’s coverage: The acceptable documenation is a letter from employer on employer’s letterhead stating employer stopped contributing toward premium.
Your employer didn’t pay the premium: The acceptable documentation is a letter from insurance company or employer on employer’s letterhead stating employer did not pay premium.
Exhaustion of COBRA continuation coverage: The acceptable documentation is a letter from employer, benefits administrator or insurance company on their letterhead showing COBRA offering and when COBRA coverage ended or will end after the full period of continuation
Employer stopped offering coverage to employees who are in a similar job classification: The acceptable documentation is a letter from employer on employer’s letterhead stating reason coverage ended or will end.
Your insurance company did not renew your plan: The acceptable documentation is a letter from insurance company stating the plan is not being renewed.
You chose not to renew your plan at the end of its plan year: The acceptable documentation is a letter from employer on employer’s letterhead stating you: Declined group coverage during the upcoming plan year and had group coverage in the previous year.
You no longer reside, live, or work in the HMO or EPO service area, and no other group plan is available to you: Letter from employer on employer’s letterhead stating you no longer reside, live, or work in service area and no other plan is offered.
Loss of individual coverage:
Your insurance company did not renew your plan on your plans anniversary date: Document needed is a letter from insurance company stating your plan will not be renewed.
You are no longer eligible for a student plan provided through an institution of higher learning by a health insurance company: Documents needed are a letter/document from the school or insurance company showing date coverage began and ended or will end and a letter or document confirming graduation, withdrawal, or leave of absence.
The Health Insurance Marketplace terminated your plan due to inconsistencies with U.S. citizenship or immigration status: Document needed is a letter from the marketplace stating coverage terminated or will terminate due to inconsistencies with U.S. citizenship or immigration status.
You no longer reside in the HMO or EPO service area: Document needed is a letter from insurance company or HMO stating that you moved outside their service area.
You are no longer eligible for Medicare Part A, NJ FamilyCare/Medicaid, TRICARE, Certain veterans programs, or the Peace Corp: Document needed is a letter from a government agency stating when coverage ended or will end.
2. Dependent attained age 26 or 31 years
You are no longer eligible because you reached the age limit: Document needed is a letter from the insurance company stating the date coverage terminated or will terminate due to age. If letter does not specify you reached the age limit, you must also provide a copy of your birth certificate or drivers license.
You gained or became a spouse through marriage (including same sex spouses) including Civil Union partners, domestic partners, or common law marriage: Documents needed include proof that marriage occurred, proof showing the date the marriage occurred, and proof that you and your spouse had minimum essential coverage or lived in a foreign country or U.S. territory for at least one day in the 60 days prior to your marriage.
4. Birth/adoption/foster care
You gained or became a dependent because of-
Birth: Documents needed are a birth certificate, a letter or medical record from a clinic, hospital, physician, midwife, institution, or other medical provider showing the date of birth. Individuals can also use a military, religious or foreign birth record showing the child’s date and place of birth.
Child placed for adoption/legally adopted: Document needed is a copy of the adopted child’s birth certificate in the name of the adopting parents together with a certificate by the parents of the date of adoption. For foreign adoptions, a U.S. Department of Homeland Security immigration document that shows the name of the person who was adopted and the date of the adoption.
Child placed through foster care: Documentation from authorized governmental body or delegating agency naming the policyholder as the foster parent.
5. Child support or other court order
Court order requires coverage of eligible dependents: Document needed is a child support or other court order showing the name of the new dependent and the date the court order is signed by a court official.
6. Access to new plans due to permanent move
You moved your primary residence to New Jersey: All of the following documents are needed- Proof of primary residence for both locations, where you lived before you move, and where you live in New Jersey, proof showing the date of move and proof you had minimum essential coverage or lived in a foreign county or U.S. territory for at least one day in the 60 days before your move. Individuals can use bills or statements, U.S. Postal Service, mortgage or rental document, government agency documents, insurance company documents, official school documents, document form an employer, or a reference letter. For proof of minimum coverage individuals can use insurance related documents, employer related documents, or government agency documents.
7. The Health Insurance Marketplace changed subsidy determination
Loss of subsidy: Document needed is a letter from the Marketplace giving you the right to a Special Enrollment Period due to loss of advanced premium tax credit or cost sharing reduction.
8. NJ FamilyCare/Medicaid denial
You were determined to be ineligible for NJ FamilyCare/Medicaid after the annual enrollment period or special enrollment period ends: Document needed is a letter from NJ FamilyCare/Medicaid showing the names of the individuals who were denied coverage and the date coverage was denied. The letter must be printed on the agency’s letterhead. Letter from NJ FamilyCare/Medicaid or from the insurance company that provided your NJ FamilyCare/Medicaid benefits showing that you had coverage and that it ended. Or a screenshot of your eligibility results from your state online application, if the denial was received online, the document must contain the name of the government agency or insurance company that denied your NJ FamilyCare/Medicaid coverage.
9. Domestic Abuse or Spousal Abandonment
Victim of domestic abuse or spousal abandonment necessitating coverage apart from the perpetrator:
Document needed is a notarized letter signed by the victim indicating they qualify for this Special Enrollment Period.