Special Enrollment Periods for Complex Cases in the Marketplace

Written by Karan Ireland

April 25, 2014

Open Enrollment for 2014 Marketplace coverage is over. Outside the Open Enrollment period, you can enroll in a private health plan through the Marketplace only if you qualify for a special enrollment period.

You can qualify for a special enrollment period if either of the following applies to you:

Other complicated cases that may qualify for a special enrollment period

Below are cases and examples that may also qualify you for a special enrollment period.

Exceptional circumstance

You faced a serious medical condition or natural disaster that kept you from enrolling. For example:

  • An unexpected hospitalization or temporary cognitive disability
  • A natural disaster, such as an earthquake, massive flooding, or hurricane
  • A planned Marketplace system outage, such as Social Security Administration system outage

Misinformation or misrepresentation

Misconduct by a non-Marketplace enrollment assister (like an insurance company, navigator, certified application counselor, or agent or broker) resulted in you:

  • Not getting enrolled in a plan
  • Being enrolled in the wrong plan
  • Not getting the premium tax credit or cost-sharing reduction you were eligible for

Enrollment error

The insurance company was unable to process your enrollment because of a technical error between the Marketplace and the insurance company.

System errors related to immigration status

An error in the processing of applications or system caused you to get an incorrect immigration eligibility result when you tried to apply for coverage.

Display errors on HealthCare.gov

Incorrect plan data was displayed at the time that you selected your health plan, such as benefit or cost-sharing information. This includes issues where some consumers were allowed to enroll in plans offered in a different area, or enroll in plans that don’t allow certain categories of family relationships to enroll together.

Medicaid/Marketplace transfers

  • If you applied for Medicaid through your state, or were sent to Medicaid from the Marketplace, but you weren’t eligible for Medicaid.
  • Your state transferred your information to the Marketplace but you didn’t get an answer about your eligibility and/or didn’t get enrolled before March 31.

Error messages

Your application was stopped due to specific error messages. For example, you received a “data sources down” error message or another error message that didn’t allow you to enroll.

Unresolved casework

You’re working with a caseworker on an enrollment issue that didn’t get resolved before March 31.

Victims of domestic abuse

You’re a victim of domestic abuse and weren’t previously allowed to enroll and receive advance payments of the premium tax credit separately from your spouse. You’ll be able to do so now.

Other system errors

Other system errors that kept you from enrolling, as determined by the Centers for Medicare & Medicaid Services

If you qualify for a special enrollment period

If you think you qualify for a special enrollment period, contact the Marketplace Call Center at 1-800-318-2596 (TTY: 1-855-889-4325)

The representative will ask for information about your situation to determine if your circumstances qualify you for a special enrollment period. The representative will help you apply and enroll in coverage.

If you’re already enrolled in a plan and you get a special enrollment period, you can stay in your current plan in most cases, or you can switch plans. In some limited cases, you may qualify for an earlier effective date of coverage. Remember, you must make the first premium payment before your coverage becomes effective.

Filing an appeal

If your request for a special enrollment period is denied, you can file an appeal. If the denial is found incorrect, you can get coverage back to the date your special enrollment period was denied.

How to file an appeal:

Health Insurance Marketplace
465 Industrial Blvd.
London, KY 40750-0061

When possible, include a copy of any eligibility determination notice or other official notice you received. This isn’t required, but will help us process your appeal.

When mailing the appeal request to the Health Insurance Marketplace, be sure to include the last 4 digits of the London, KY Zip code (40750-0061). This will help your appeal arrive faster.

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