EVENT SPECIAL ENROLLMENT PERIOD (SEP)
Requirements for individual and family plans (ACA/GF/GM)
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 |
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| 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 |
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| 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