Proving you qualify for a special enrollment period

It’s essential that people have the ability to enroll in a health insurance plan when they have a bona fide change in circumstances. If you move to a new state in April, you can’t be expected to wait until the next annual open enrollment period beginning November 1 (in most states) to sign up for health insurance coverage that starts in January in your new location (assuming you were already insured prior to the move).

And if you leave your job in June and lose your employer-sponsored insurance that month, it wouldn’t make sense for you to have to wait until open enrollment to sign up for a new plan that would take effect in January.

That’s why qualifying life events and special enrollment periods (SEPs) were built into the Affordable Care Act.

Early on, qualifying events were on the ‘honor system’

But it wasn’t all smooth sailing in the early years after the ACA went into effect. Until 2016, HealthCare.gov didn’t require applicants to prove that they’d experienced a qualifying life event. Applicants had to attest that they had a qualifying life event, but it was basically on the honor system.

By late 2015, it had become apparent that healthcare utilization was significantly higher among people who enrolled during special enrollment periods, and also that those individuals tended to keep their coverage for a shorter duration than people who signed up during open enrollment.

Despite the fact that the eligibility requirements were relatively lax in 2014 and 2015, it can’t be said for sure that people were “gaming the system” and signing up when they didn’t actually have a qualifying life event. Another explanation could be simply that people who are sick are much more likely to seek out coverage when they do have a qualifying life event, as opposed to someone who’s healthy.

A sick person who loses access to an employer-sponsored plan may go to great lengths to secure new coverage during a special enrollment period. But a healthy person in the same situation might gamble on being uninsured for a while, and just wait until open enrollment comes around again.

And in terms of attrition (people canceling their coverage), HHS noted in late 2016 that they hadn’t found attrition rates to be different based on when people enroll, “suggesting that any such gaming [the system], if it is occurring, does not appear to be occurring at sufficient scale to produce statistically measurable effects.”

Some advocates have argued that SEP access should be as simple as possible in order to cast a wide net and encourage everyone with qualifying life events to enroll. Families USA has noted that while sick people are willing to jump through whatever hoops are necessary in order to get coverage, healthy people (who tend to be younger) might not be. They contend that requiring proof of eligibility to enroll outside of open enrollment could actually have a deleterious effect on the overall risk pool.¹, ²

Nonetheless, the general consensus among health insurance carriers by late 2015 was that SEP enrollments were hurting their bottom line, and many insurers took steps to reduce or eliminate broker commissions for plans purchased outside of open enrollment, in an effort to curtail sales during that time.

Exchanges now require proof of qualifying life events

To address insurer concerns and help stabilize the individual health insurance market, HealthCare.gov’s then-CEO Kevin Counihan noted in January 2016 that the exchange would take steps to enforce the eligibility requirements for SEPs. And by February, the Centers for Medicare & Medicaid Services (CMS) clarified that they would be implementing documentation requirements for proof of qualifying life events when people enroll through HealthCare.gov outside of open enrollment.³

The new SEP eligibility verification process was finalized in May 2016⁴ and implemented in June 2016 (and subsequently ramped up in 2017, with the market stabilization rule). In September 2016, HHS answered several frequently asked questions regarding the verification process for qualifying life events. At that point, SEP enrollments since June were about 15% below where they had been during the same time period the year before. (They had been roughly even with 2015 numbers in the months leading up to the implementation of the new eligibility verification process.)

But HHS did not assign a reason for the decline: it could be that people were previously “gaming the system” (ie, enrolling without a valid qualifying life event), but it could also be that the process for enrolling had become more onerous due to the added verification step, making healthy enrollees less likely to complete the process.⁵ Families USA had noted in early 2016 – before the new SEP eligibility verification rules went into effect – that fewer than 15% of people who were eligible for SEPs had used them, and had expressed concerns that the new eligibility verification process could exacerbate the low utilization rate.⁶

Starting in June 2017, HHS was planning to implement a pilot program to further enhance SEP eligibility verification. This plan was created by HHS under the Obama Administration, but it was changed from a pilot to a universal program under the Trump administration.⁷ The pilot program was slated to randomly select 50% of SEP enrollees and pend their enrollments until they submitted proof of a qualifying life event.

But the Trump administration increased this to 100% of enrollments, rather than implementing the pilot program that would have required pre-enrollment verification for half of enrollees. Under the program, applicants had 30 days to submit their proof of SEP eligibility, and as long as they did so, their new coverage would be effective as of the date determined by the date of their application/plan selection (in other words, there is no deleterious effect for people who do have a valid qualifying life event).

The SEP verification process tends to proceed relatively quickly, but in cases where it’s delayed the enrollee has the option of keeping the original (retroactive) effective date and paying all of the necessary premiums, or switching to a prospective effective date and paying just one month’s premium in order to effectuate the coverage.

Some state-run exchanges were already requiring proof of SEP eligibility prior to 2016, and most others have followed HealthCare.gov’s lead and implemented documentation requirements. HHS proposed a rule change for 2022 that would have required state-run exchanges to verify SEP eligibility for at least 75% of new enrollees who submit applications outside of the open enrollment window. That proposal was not finalized, however, as HHS determined that it wasn’t necessary.

The agency noted that as of 2021, only four of the state-run exchanges had SEP verification processes that were less stringent than HealthCare.gov’s, and that those exchanges had confirmed that their participating insurers were not seeing any “misuse of special enrollment periods” under the existing rules. But again, most of the state-run exchanges have SEP verification protocols that are just as robust as HealthCare.gov’s.

SEP verification rules relaxed

Starting in 2023, HealthCare.gov opted to scale back the pre-enrollment verification process for special enrollment periods.⁸ Loss of coverage is the only qualifying life event that now requires the enrollee to submit proof of the qualifying life event prior to enrollment,⁹ although that’s the most commonly used qualifying life event.¹⁰

In the state-run exchanges, used in 18 states and DC as of 2024, the exchanges have the option to continue to require pre-enrollment proof of any qualifying life events.⁸ If an exchange opts to require pre-enrollment verification of SEP eligibility, the exchange can provide exceptions in circumstances where the verification process would cause undue burden for the applicant, as long as exceptions are provided in a non-discriminatory manner.¹¹

As a general rule of thumb, if you already have health insurance, you’ll have a chance to switch coverage when you experience certain qualifying life events, particularly if they mean that you can no longer keep your old plan (For example, you stop working for the employer that provided you with group health coverage, or move out of your plan’s service area.)

And if you don’t have coverage, you’ll still have a chance to enroll in a new plan if you experience one of a handful of qualifying life events such as having a baby or gaining lawfully present resident/U.S. citizen status.

Some qualifying life events that trigger a SEP – such as getting married or moving to a new area – used to allow uninsured people to secure coverage, but the marketplace stabilization rules ended that as well.

In the case of marriage, the current rules require at least one spouse to have minimum essential coverage prior to the marriage; two uninsured people will not have access to a SEP if they get married. And moving to a new area will only trigger a SEP if the person had minimum essential coverage prior to the move.

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Louise Norris is an individual health insurance broker who has been writing about health insurance and health reform since 2006. She has written dozens of opinions and educational pieces about the Affordable Care Act for healthinsurance.org.

1. “Re: RIN 0938-ZB39 Reducing Regulatory Burdens Imposed by the Patient Protection and Affordable Care Act & Improving Healthcare Choices To Empower Patients” Families USA. Feb. 24, 2016 ⤶
2. “Administration Tightens Documentation Standards For ACA Special Enrollment Periods” Families USA. July 12, 2017 ⤶
3. ”Fact Sheet: Special Enrollment Confirmation Process” CMS Newsroom. Feb. 24, 2016 ⤶
4. ”Special Enrollment Periods for the Health Insurance Marketplace” CMS Newsroom. May 6, 2016 ⤶
5. ”CMS Sees Drop In Special Enrollment Period Selections, Plans Further Steps” Health Affairs. Sep. 6, 2016 ⤶
6. “Administration Tightens Documentation Standards For ACA Special Enrollment Periods” Families USA. Feb. 24, 2016 ⤶
7. ”Proposed Pre-Verification Process for Special Enrollment Periods: Policy Goals, Potential Impact, and the need for State Flexibility” CHIR Blog. Mar. 29, 2017 and “The Ins and Outs of the New Approach to Special Enrollment Periods: Pre-enrollment Verification (SEPV)” CHIR Blog. June 9, 2017 ⤶
8. ”HHS Notice of Benefit and Payment Parameters for 2023 Final Rule Fact Sheet” Centers for Medicare & Medicaid Services. April 28, 2022. ⤶ ⤶
9. ”Special Enrollment Periods” Centers for Medicare & Medicaid Services. Accessed March 7, 2024. ⤶
10. ”Federally-facilitated Exchange (FFE) Enrollment Manual” Centers for Medicare & Medicaid Services. July 12, 2023. ⤶
11. ”§ 155.420(g) Pre-enrollment special enrollment period verification” Code of Federal Regulations. Accessed June 19, 2024 ⤶