Special Enrollment Period (SEP)

A time outside the yearly Open Enrollment Period when you can sign up for health insurance. You qualify for a Special Enrollment Period if you’ve had certain life events, including losing health coverage, moving, getting married, having a baby, or adopting a child.  If you qualify for an SEP, you usually have up to 60 days following the event to enroll in a plan. If you miss that window, you have to wait until the next Open Enrollment Period to apply.
 

There are 4 basic examples of qualifying life events.

• Loss of health coverage
  • Losing existing health coverage, including job-based, individual, and student plans
  • Losing eligibility for Medicare, Medicaid, or CHIP
  • Turning 26 and losing coverage through a parent’s plan
• Changes in household
  • Getting married or divorced
  • Having a baby or adopting a child
  • Death in the family
• Changes in residence
  • Moving to a different ZIP code or county
  • A student moving to or from the place they attend school
  • A seasonal worker moving to or from the place they both live and work
  • Moving to or from a shelter or other transitional housing
• Other qualifying events
  • Changes in your income that affect the coverage you qualify for
  • Gaining membership in a federally recognized tribe or status as an Alaska Native Claims Settlement Act (ANCSA) Corporation shareholder
  • Becoming a U.S. citizen
  • Leaving incarceration (jail or prison)
  • AmeriCorps members starting or ending their service

GetCoveredNJ Qualifying Events - SEP

• Adoptions / Court ordered
• Birth
• Change in incarcerations status
• Change in legal presence
• Exceptional Circumstance or Plan/Program Error
• Gain of INdian/Alaska Native status
• Loss of employer-based health insurance coverage
• Loss of Familycare, Medicaid, CHIP or Medicare
• Lost or will lose health insurance coverage
• Marriage
• Moved into State
• Pregnancy
• Survivors of domestic violence, abuse or spousal abandonment

If you're enrolled in a small group health plan that is enrolling, you may be eligible for a SEP if your employer's plan is deemed "unaffordable".

You will not be eligible for a tax credit (premium reduction) thru GetCoveredNJ if your employer's plan is considered affordable.

When it comes to the ACA, affordability is determined by a percentage of income threshold. In 2023, for coverage to be considered affordable it must cost no more than 9.12 percent of an employee's annual salary.

What documents can I submit?

Documents must show that you lost qualifying health coverage in the past 60 days or will lose coverage in the next 60 days. These documents must include your name and the date of coverage loss. Documents you can submit:
 

• A letter from an insurance company, on official letterhead or stationery, including:
  • A letter or premium bill from your former insurance company that shows you or your dependent’s cancellation/termination from health coverage.
  • A decertification letter from your insurance company stating when coverage will no longer be offered.
• A letter from an employer, on official letterhead or stationery, that confirms one of these about you or your spouse or dependent family member:
  • That your employer dropped or will drop your coverage or benefits.
  • That your employer stopped or will stop contributing to your cost of coverage.
  • That your employer changed or will change coverage or benefits, and your coverage will no longer be considered qualifying health coverage.
• A letter about COBRA coverage, like a letter from an employer or health insurance company that confirms these:
  • Your employer’s offer of COBRA coverage along with the date this coverage would start.
  • Your COBRA coverage ended or will end, or your employer stopped or will stop contributing to the cost of coverage and when.
• A health care program document, on official letterhead or stationery, including:
  • A letter from a government health program, like TRICARE, Veterans Affairs (VA), Peace Corps, or Medicare, showing when coverage ended or will end.
  • A letter from your state Medicaid or CHIP agency showing that your eligibility for Medicaid or CHIP was denied and when it was denied or that your Medicaid or CHIP coverage ended or will end.
  • A dated copy of your military discharge document (DD214).
• A letter if you lost student health coverage, which shows when the coverage ended or will end. This should be on official letterhead or stationery.

You can also submit any of the documents in the list below. However, these documents may include only some of the information we need to confirm, so you’ll most likely need to submit more than one of these documents:

• Pay stubs, if you lost employer-sponsored coverage. You can submit:
  • 2 pay stubs from the past 1-3 months, one that shows a deduction for health coverage and another which shows that the deduction ended in the past 60 days.
  • If a reduction in work hours caused you to lose coverage, you can submit one previous pay stub that shows that you worked 30 or more hours and a deduction for health coverage, and a pay stub from the past 60 days that shows that you worked less than 30 hours and no deduction for health coverage.
• Document showing you lost coverage because of divorce, legal separation, custody agreements, or annulment within 60 days of submitting your application, including:
  • Divorce or annulment papers that show the date responsibility ends for providing health coverage or proof that you stopped getting health coverage because of your relationship to your former spouse.
  • Legal separation papers that show the date responsibility ends for providing health coverage.
  • Other confirmation that you lost or will lose coverage because of divorce, legal separation, or annulment that shows the date that health coverage ends.
• Document showing you lost coverage due to death of a family member, including:
  • A death certificate or public notice of death and proof that you were getting health coverage because of your relationship to the deceased person, like a letter from an insurance company or employer that shows the names of the people on the health plan.
  • Other confirmation that shows you lost or will lose coverage because of the death of a spouse or other family member.

What if I don't have any of these documents?

You can submit a letter explaining the coverage you had, why and when you lost it or will lose it, and the reason you can't provide documents.