National Disability Navigator Resource Collaborative

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Fact Sheet #21

Special Enrollment Periods – What People with Disabilities Need to Know

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Introduction

While Open Enrollment may be limited to a specific time in the year, individuals can potentially qualify for a special enrollment period (SEP) throughout the year. Individuals can qualify for SEPs for many reasons and there are several resources available which provide a full breakdown of these qualifying events.

  • For enrollment assisters: This concise reference chart from the Center on Budget and Policy Priorities describes marketplace special enrollment periods and the prior coverage requirements, effective dates, and plan switching limitations for each SEP.
  • For current and prospective marketplace enrollees: The Centers for Medicare and Medicaid Services’ (CMS) Understanding Special Enrollment Periods guide provides information on SEPs and how to access them in states that use HealthCare.gov that may be helpful for people with disabilities.

This factsheet provides specific information on the availability of SEPs for people with disabilities and unique circumstances that they may face.

Q1. Is someone who recently became disabled eligible for a special enrollment period?

No, but if the disability is accompanied by job loss or losing healthcare coverage, then yes. For example, if an individual with employer coverage experiences an accident that places them in a hospital for an extended period and in turn causes them to lose their job, they would qualify for a loss of employer coverage SEP. Cases can vary but if the outcome leads to a change in income that affects eligibility for Medicaid or marketplace financial assistance, loss or gain of dependents, or a permanent move, the individual can qualify for an SEP.

Additionally, people who have an annual household income between 100-150% of the FPL are eligible for an SEP at any time (and up to one time per month), so if a new disability causes the individual’s income to drop below 150% of the FPL, they could be eligible for an SEP.

Q2. Can someone get an extension of time for an SEP if a disability prevents them from signing up for coverage during the applicable 60-day or 90-day window?

Yes, if a person experiences an exceptional circumstance that prevents them from accessing the SEP during the regular window, for example if the person has a serious medical condition, like an unexpected hospitalization or a temporary cognitive disability. This can be completed up to 60 days after they are determined eligible for an SEP.

Q3. Is a person who recently lost their Medicaid coverage eligible for a special enrollment period?

Yes, losing Medicaid coverage outside of the open enrollment period can qualify someone for a special enrollment period, also known as the “Unwinding SEP.”

This SEP allows individuals in states with Marketplaces served by the HealthCare.gov platform to enroll in Marketplace coverage. Marketplace-eligible consumers who submit a new application or update an existing HealthCare.gov application between March 31, 2023, and November 30, 2024, and attest that they have lost Medicaid or CHIP coverage in the same time period are eligible for the Unwinding SEP. These individuals then have 60 days after they receive their eligibility determination to select a plan with coverage that will start on the first day of the month after they select a plan. Individuals will not be required to submit documentation to verify loss of Medicaid or CHIP to qualify for the Unwinding SEP.

Note that after the Unwinding SEP expires, loss of Medicaid or CHIP still triggers a 90-day SEP.

Q4. What information does someone with a disability need to submit to qualify for a special enrollment period?

If the marketplace requires additional information to verify a person’s eligibility for an SEP, details and instructions will be provided through a Marketplace eligibility notice. Individuals can pick a plan, but they must submit documentation within 30 days. Coverage will not begin until the Marketplace confirms eligibility. Some SEPs do not require any documentation; if this is the case, the person can immediately pick a plan and enroll.

Documentation that might be required to confirm eligibility for the loss of Minimum Essential Coverage SEP can include a letter from an insurance company detailing the end of coverage or termination from health coverage; a letter from an employer stating a drop in coverage or benefits; a health care program document showing a person has been determined ineligible for coverage; or a letter showing loss in student health. In addition, if documentation isn’t readily available, a person can also submit a letter to the marketplace explaining their situation. A template is available from HealthCare.gov here.

If a person does not have any of the document mentioned above, the following documents are also acceptable, although it is likely that the person would have to submit multiple documents in order to get the marketplace all of the information it needs to verify SEP eligibility: pay stubs to confirm loss of employer-sponsored coverage; documents detailing loss of coverage due to divorce, legal separation, custody agreements, or annulments; or documentation of a death of a family member leading to loss of coverage. More information on proof of coverage loss documentation is available at HealthCare.gov.

These documents can be uploaded through the person’s Marketplace account under “My Applications and Coverage” or photocopies can be mailed along with the printed bar code from the last page of the eligibility notice or the application ID to the Health Insurance Marketplace (Attn: Supporting Documentation, 465 Industrial Blvd., London, KY 40750-0001). More information on how to upload or send documents for an SEP can be found at HealthCare.gov.

A notice will be sent through the person’s Marketplace account or via mail to the address provided.

Q5. What resources can people use to find out more about a special enrollment period?

  • If an individual believes that they qualify for an SEP, they can contact the Marketplace call center at 1-800-318-2596 or 1-855-889-4325 for TTY services.
  • The Kaiser Family Foundation has extensive FAQs on the Health Insurance Marketplace and the ACA Enrollment Periods.
  • The Administration for Community Living’s Disability Information and Access Line at 1-888-677-1199 or at acl.gov/home to obtain information about essential services for people with disabilities.
  • Topical factsheets for people with disabilities from the National Disability Navigator Resource Collaborative.

Conclusion

As of the writing of this factsheet, Medicaid redeterminations are still on-going as a result of the unwinding of the Medicaid continuous coverage requirement. The 2022 American Community Survey reported that 30% of Medicaid enrollees had a disability, highlighting the importance of the Medicaid redeterminations and special enrollment periods to ensure that the disability population continues to receive accessible and affordable healthcare coverage. For those who missed the Open Enrollment period, there are still opportunities to qualify for an SEP to enroll in Marketplace coverage. Knowledge about which SEPs are available and how to access them can help people with disabilities maintain continuous coverage if they experience changes in their household size, income, and eligibility for other forms of coverage throughout the year.

 

*The American Association on Health and Disability would like to acknowledge the Center on Budget and Policy Priorities for providing the resources to make this fact sheet available.