17. How do Special Enrollment Periods (SEPs) affect the start date of coverage?
Most SEPs consist of a 60 day period in which an individual can enroll prospectively by selecting a plan and paying the premium by the 23rd of the month for coverage to begin in the following month. However, certain SEPs may allow for a retroactive effective date.
The SEP for the birth or adoption of a child provides for retroactive enrollment in a QHP to the date of birth or adoption. However, a child born to a mother enrolled in ConnectorCare will ordinarily be eligible for MassHealth. If the mother is not on MassHealth, newborn coverage is only retroactive for 10 days from application. The birth to a mother who is not herself enrolled in MassHealth should be reported within 10 days of birth to assure that if the child is eligible for MassHealth, enrollment will go back to the date of birth.
Certain other SEPs allow for a special effective date of coverage based on the circumstances of the SEP and may also be retroactive. They include: enrollment or non-enrollment due to error by the Connector, its agents, or by enrollment assisters, the plan’s material violation of its contract, a MassHealth determination of ineligibility that does not occur until after Connector enrollment periods have expired, other material error, other exceptional circumstances such as hospitalization or a death in the family or, at the option of the Connector, satisfactory verification of eligibility following denial for failure to verify. 45 CFR 155.420(b)(2)(iii). As a practical matter the effective date in these situations is usually worked out through a 3-way negotiation among the applicant/enrollee, Health Connector staff and the health plan. The denial of an SEP is appealable as discussed in a later Q & A.