16. What qualifying events create a special enrollment period (SEP)?

Federal law requires certain qualifying events but state-based Marketplaces like the Health Connector can also define additional qualifying events. An individual applying online or by telephone will be asked about the existence of a qualifying event if that is needed to enroll. An individual applying by paper who needs a qualifying event to enroll will receive a notice with information about how to request a special enrollment period  along with the eligibility determination.

Being found newly eligible for ConnectorCare automatically triggers a special enrollment period without an applicant having to ask for it. This is by far the most important qualifying event added by the Health Connector. 

For all other qualifying events, the applicant must request an SEP, and the Health Connector must agree that an SEP applies before an individual can enroll. An individual may also be asked to supply proof of the qualifying event within 90 days. If proof is not supplied, the individual will be terminated from coverage. Within 35 days of the termination notice, the individual can request reinstatement in the same plan provided he or she submits the proof and pays the premium for the balance owed and the next month. If the Health Connector denies a request for an SEP, it issues a written decision that is subject to appeal.

Qualifying events defined in federal law, 45 CFR 155.420

  • A change in household because of: 
    • Marriage  
    • Birth
    • Adoption or placement for adoption 
    • Death, divorce or legal separation from spouse
  • A loss of health insurance because of: 
    • Loss of job or reduced hours 
    • Change in job or move outside service area of current plan 
    • Change in eligibility for employer plan or significant change in plan options 
    • Change in employer plan or employee’s FPL such that employer plan no longer affordable or minimum value 
    • No longer MassHealth eligible o Loss of coverage on parent’s plan on turning 26 
    • Health plan no longer QHP 
    • Expiration of COBRA 
    • No longer student health plan eligible

NOTE: Loss of coverage based on failure to pay premiums or voluntarily terminating coverage is not a qualifying event.

  • Changes making an individual newly eligible  
    • A change in status as US citizen or lawfully present immigrant
    • A change in FPL that makes an unsubsidized QHP enrollee or dependent newly eligible for PTC or ineligible for PTC 
    • Release from incarceration  
    • Permanent move to Massachusetts from prior place of residence 
  • Victims of domestic abuse or spousal abandonment and dependents who are enrolled in coverage with the abuser or the abandoning spouse and seek to obtain separate coverage
  • An applicant who is assessed as potentially eligible for MassHealth and is determined ineligible for MassHealth after open enrollment has ended or initial SEP expired.
  • Individuals who gain or maintain status as an Indian and their dependents; they may enroll or change QHP one time per month
  • Special circumstances affecting enrollment include: 
    • Enrollment or failure to enroll due to error, misrepresentation or inaction by the Health Connector, certified application counselors or Navigators  
    • The individual demonstrates that material error influenced decision to enroll or not enroll 
    • Misconduct by a Navigator, broker or certified application counselor 
    • The ConnectorCare plan/QHP significantly violated its contract with the consumer 
    • At the option of  the Health Connector, the individual provides satisfactory evidence to verify eligibility after termination due to failure to verify within the required period 
    • The consumer experienced other exceptional circumstances preventing enrollment as the Connector may provide, this currently includes hospitalization or a death in the family

Additional qualifying events in ConnectorCare regulations, 956 CMR 12.10(5)(b)-(e)

  • Being determined newly eligible for ConnectorCare 
    • Applicants do not have to identify this qualifying event or request an SEP, HIX will recognize when an applicant is newly eligible for ConnectorCare. However this qualifying event will not help an individual who was previously found eligible for ConnectorCare and did not enroll by the deadline. He or she will have to wait until open enrollment unless another qualifying event applies.
  • A change to a different one of the three Plan Types for an existing enrollee.
  • Approval of a premium hardship waiver. 
  • The expiration of a hardship waiver. 

Individuals generally have 60 days to enroll or change plans from the date of one of these triggering events. 

Additional qualifying events in state law: OPP waiver, 958 CMR 4.00

  • If the Health Connector denies enrollment because someone does not have a qualifying life event and open enrollment has ended, the denied applicant can request a waiver from the Office of Patient Protections (OPP), an office of the Health Policy Commission. 
  • The waiver request must be filed within 30 days of the denial notice and include a copy of the denial. The waiver form asks the applicant to explain why they did not enroll during open enrollment or after losing coverage and the applicant must certify that he or she did not intentionally forego coverage. If a waiver is granted, the individual may return to the Connector and complete enrollment. 

See also, Health Connector Policy, NG-1E, Mid-Year Life Events or Qualifying events, rev. Jan. 27, 2016