SEP Enrollment Rules


SEP Enrollment Rules

EVENT SPECIAL ENROLLMENT PERIOD (SEP) SEP Enrollment Rules

Requirements for individual and family plans (ACA/GF/GM)

SEP Enrollment Rules

Special enrollment event

Event notification timeframe

Individual eligible to enroll in coverage or be added to existing policy/certificate

Coverage effective date

Documentation Requirement*

INCREASE OR DECREASE IN PROJECTED ANNUAL INCOME FOR 2016 OR CHANGE TO CURRENT MONTH’S INCOME

Newly ineligible for subsidy

60 days prior to event and within 60 days of event

Individuals who lost coverage

Receipt date between the 1st and 15th of the month, first of the month following receipt date. Receipt date between the 16th and the end of the month, first of the second month following receipt date.

Proof from CMS of subsidy eligibility change

ADD OR REMOVE APPLICANT OR NON-APPLICANT HOUSEHOLD MEMBER LISTED ON APPLICATION

Marriage, including common law

60 days prior to event and within 60 days of event

Individual, spouse and all dependents

Receipt date between the 1st and 15th of the month, first of the month following receipt date. Receipt date between the 16th and the end of the month, first of the second month following receipt date.

Marriage certificate, Common law affidavit (if applicable)

Domestic Partnership

60 days prior to event and within 60 days of event

Individual and dependents, domestic partner and domestic partner’s dependents

Receipt date between the 1st and 15th of the month, first of the month following receipt date. Receipt date between the 16th and the end of the month, first of the second month following receipt date.

Certification of Domestic Partnership form

Birth

Within 60 days of event

Individual, spouse and all dependents, including newborn

The date of the birth

Birth certificate, letter from the hospital, or medical records

Adoption/foster care

60 days prior to event and within 60 days of event

Individual, spouse and all dependents, including newly gained dependent

The date of the adoption, placement for adoption, or placement in foster care.

Adoption or foster care documentation

Legal guardianship

60 days prior to event and within 60 days of event

Individual, spouse and all dependents, including newly gained dependent

The date of the legal guardianship

Legal guardianship documentation

Court ordered coverage

60 days prior to event and within 60 days of event

Individuals named in court order

The date of the required court ordered coverage

Court order

PERMANENT MOVE

Access to qualified health plan due to a permanent move

60 days prior to event and within 60 days of event

Individuals who have had prior coverage and make a permanent move, giving the member access to a new QHP

Receipt date between the 1st and 15th of the month, first of the month following receipt date. Receipt date between the 16th and the end of the month, first of the second month following receipt date.

Proof of old residency and new residency (e.g. old drivers license or mail from prior address and from new address); Release from incarceration is not eligible for SEP.**

LOSS OF OTHER HEALTH COVERAGE

Death of a policyholder/

certificate holder

Within 60 days of event

Individuals who lost coverage

Receipt date between the 1st and 15th of the month, first of the month following receipt date. Receipt date between the 16th and the end of the month, first of the second month following receipt date.

Death certificate or obituary, letter of loss of coverage from prior carrier

Dependent turning 26

60 days prior to event and within 60 days of event

Individual who lost coverage due to turning 26

Receipt date between the 1st and 15th of the month, first of the month following receipt date. Receipt date between the 16th and the end of the month, first of the second month following receipt date.

Letter of loss of coverage from prior carrier

Dependent 19-25

60 days prior to event and within 60 days of event

Individual being removed from parent’s contract between the ages of 19-25

Receipt date between the 1st and 15th of the month, first of the month following receipt date. Receipt date between the 16th and the end of the month, first of the second month following receipt date.

Letter of loss of coverage from prior carrier

Continued on next page

Continued from previous page

Special enrollment event

Event notification timeframe

Individual eligible to enroll in coverage or be added to existing policy/certificate

Coverage effective date

Documentation Requirement*

Divorce/dissolution of domestic partnership

60 days prior to event and within 60 days of event

Spouse and dependents being removed due to divorce

Receipt date between the 1st and 15th of the month, first of the month following receipt date. Receipt date between the 16th and the end of the month, first of the second month following receipt date.

Divorce decree or letter of loss of coverage from prior carrier

Exhaustion of COBRA or Continuation

Coverage

60 days prior to event and within 60 days of event

Individuals who lost coverage

Receipt date between the 1st and 15th of the month, first of the month following receipt date. Receipt date between the 16th and the end of the month, first of the second month following receipt date.

COBRA termination letter or letter of loss of coverage from prior carrier

Loss of Medicaid or Hawk-I eligibility

(IA) or CHIP (SD)

60 days prior to event and within 60 days of event

Individuals who lost coverage

Receipt date between the 1st and 15th of the month, first of the month following receipt date. Receipt date between the 16th and the end of the month, first of the second month following receipt date.

Notification of loss of eligibility and coverage

Policyholder or certificate holder enrolls in Medicare

60 days prior to event and within 60 days of event

Individuals who lost coverage

Receipt date between the 1st and 15th of the month, first of the month following receipt date. Receipt date between the 16th and the end of the month, first of the second month following receipt date.

Copy of Medicare card of eligible individual or letter of loss of coverage from prior carrier

Termination of employment or reduction in hours

60 days prior to event and within 60 days of event

Individuals who lost coverage

Receipt date between the 1st and 15th of the month, first of the month following receipt date. Receipt date between the 16th and the end of the month, first of the second month following receipt date.

Letter from employer or letter of loss of coverage from prior carrier

Return from military service

60 days prior to event and

60 days from date of event

Individual returning from military service and his/her spouse and dependents

Receipt date between the 1st and 15th of the month, first of the month following receipt date. Receipt date between the 16th and the end of the month, first of the second month following receipt date.

Discharge papers or letter of loss of coverage from prior carrier (i.e. Tricare)

CHANGE IN IMMIGRATION STATUS OR CITIZENSHIP

Gained U.S. Citizenship

60 days prior to event and within 60 days of event

Individuals who gained citizenship

Receipt date between the 1st and 15th of the month, first of the month following receipt date. Receipt date between the 16th and the end of the month, first of the second month following receipt date.

Proof of US citizenship

Obtain Legal Immigration Status

60 days prior to event and within 60 days of event

Individuals who gained legal immigration status

Receipt date between the 1st and 15th of the month, first of the month following receipt date. Receipt date between the 16th and the end of the month, first of the second month following receipt date.

Lawful immigration documents

Changes to available employer coverage

Loss of group coverage

60 days prior to event and within 60 days of event

Individuals who lost coverage

Receipt date between the 1st and 15th of the month, first of the month following receipt date. Receipt date between the 16th and the end of the month, first of the second month following receipt date.

Letter from employer or letter of loss of coverage

from prior carrier

Employer renewal date is outside of an annual open enrollment period for the Individual Health Plan market

60 days prior to event and within 60 days of event

Individuals who lost coverage

Receipt date between the 1st and 15th of the month, first of the month following receipt date. Receipt date between the 16th and the end of the month, first of the second month following receipt date.

Letter from employer

* Documentation Requirement — In addition to the documents listed, an Application (new business) or Contract Change Form (existing members) is required.
**Proof of prior coverage will be required in addition to current documentation requirement.
NOTE: At this time, coverage effective dates will continue to follow the rules already in place.
Wellmark Blue Cross and Blue Shield of Iowa, Wellmark Health Plan of Iowa, Inc. and Wellmark Blue Cross and Blue Shield of South Dakota are independent licensees of the Blue Cross and Blue Shield Association.
Confidential and Proprietary – Wellmark Blue Cross and Blue Shield
03/16 #11635