Required Documentation for Special Enrollment Period

A Special Enrollment Period (SEP) is a 60-day period during which an eligible individual may enroll in an individual plan or change from one plan to another as a result of one of the following triggering events.

  • Loss of minimum essential coverage or loss of federal program eligibility
  • Gaining or becoming a dependent
  • Access to new individual plan due to permanent move
  • Change in eligibility for On-Marketplace coverage—Losing Advance Premium Tax Credit (APTC) or Cost-Sharing Eligibility only
  • Enrollment or plan error
  • Domestic abuse or spousal abandonment

If changing from one plan to another, the individual must stay within the same metal level of coverage as their current plan offering.

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The list below are examples of events and documentation. It is not a complete list.

Loss of Coverage 

Eligible Effective Date: First day of the month following enrollment

You may qualify for this SEP if you or anyone in your household lost qualifying health coverage in the past 60 days OR expects to lose coverage in the next 60 days.

Your submitted documentation must include:

  • Proof of loss of coverage; and
  • Proof showing the date you lost coverage; and
  • Proof of the reason you lost coverage.

A loss of coverage due to nonpayment of premium, fraud, or misrepresentation shall not be a qualifying event unless it was committed by the employer. In addition, voluntary dropping of other coverage is not a qualifying event.

Example Event

Example Documentation

Legal Separation

Legal documentation and document from previous insurance company showing termination with date

Divorce

Divorce decree and document from previous insurance company showing termination with date

Child Loses Dependent Status

Document from previous insurance company showing termination with date

Death of an Employee or Policyholder

Death certificate
Exhaustion of COBRA continuation coverage

COBRA exhaustion letter

Losing Employer Coverage

Letter from employer on letterhead

Losing Government Coverage

Letter from previous insurance company

Gaining or Becoming a Dependent

Eligible effective date for gaining or becoming a dependent through marriage, common law marriage, civil union partner, or domestic partner: First day of month following enrollment

Eligible effective date for gaining or becoming a dependent through birth or adoption: The date of birth, adoption or placement for adoption

Your submitted documentation must include:

  • Proof of gaining or becoming a dependent; and
  • Proof showing the date of gaining or becoming a dependent; and
  • Proof of previous minimum essential coverage for marriage or partnerships.

One individual in each marriage/partnership must have had minimum essential coverage for one or more days in the 60 days preceding their marriage/partnership. Exceptions are for individuals living outside of the United States or in a United States territory.

Example Event

Example Documentation

Marriage (includes same sex spouses)

Copy of marriage license and copy of ID card or letter from previous insurance company that shows someone had prior coverage

Domestic Partner

Copy of certificate of domestic partnership and copy of ID card or letter from previous insurance company that shows someone had prior coverage

Birth

Birth certificate

Child Placed For Adoption or Legally Adopted

Documentation from state-approved and accredited adoption agency naming the child as being formally placed for adoption with name of prospective parents 

Child Placed in Foster Care

Documentation from an authorized government body or agency naming the policyholder as the foster parent

Permanent Move To Capital BlueCross Service Area

Eligible effective date: First day of the month following enrollment

Your submitted documentation must include:

  • Date of the move from another state or country; and
  • Proof of prior residence in another state or country; and
  • Proof of residence in our 21-county service area; and
  • Proof of previous minimum essential coverage.

Individuals must have minimum essential coverage for one or more days in the 60 days preceding the permanent move. Exceptions are for individuals living outside of the United States or in a United States territory. There is also an exception for individuals who were previously incarcerated (within 60 days), or an individual who was in a coverage gap in a non-Medicaid expansion state prior to the permanent move. Moving only for medical treatment or residence for vacation are not qualifications for a Special Enrollment Period.

Example Event

Example Documentation

Move to Capital BlueCross Service Area

Proof of residence with previous address and current address by providing:

  • Driver’s license
  • Car registration
  • Auto insurance policy
  • Deed
  • Income tax return
  • Utility Bill
  • Lease
  • Homeowner’s/renter’s insurance policy
  • Mover’s receipt

Proof of prior minimum essential coverage by providing:

  • ID card
  • Letter from previous insurance company

Loss of Advance Premium Tax Credit (APTC) or Cost-Sharing 

Eligible effective date: First day of the month following enrollment

Your submitted documentation must include:

  • Proof that you lost APTC or Cost-Sharing; and
  • Proof showing the date it was effective.

Example Event

Example Documentation

Loss of APTC or Cost-Sharing
Documentation from the Marketplace

Enrollment or Plan Error

Eligible effective date: First day of the month following enrollment

Your submitted documentation must include:

  • Proof of the error; and
  • Proof showing the date the error occurred.

Example Event

Example Documentation

Error of the Issuer

Documentation that displays the error and details of the error, subject to issuer determination

Enrollment or nonenrollment in a plan is unintentional, inadvertent or erroneous and is the result of the error, misrepresentation, misconduct, or inaction of an office, or employee of Capital BlueCross, providing enrollment assistance or conducting enrollment activities.

Applies to the contract holder or dependents on the plan

 

Experience a plan contract violation

Documentation that displays the violation

An enrollee or his or her dependents adequately demonstrates to Capital BlueCross that the plan in which he or she is enrolled substantially violated a material provision of its contract in relation to the enrollee.

 

Medicaid/CHIP Denial

A letter from Medicaid or CHIP that shows the denial date and denial reason; and the original application date.

This is a valid SEP, if the application to Medicaid or CHIP occurred during the open enrollment period, or special enrollment period and the denial was received after the close of those periods.