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.

If you are changing plans, you must select a plan that is the same metal level of coverage as your current plan.

Provide the following:

  1. Proof that the triggering event occurred
  2. Proof of the date the event occurred.
  3. In some cases, proof of minimum essential coverage prior to SEP event.

Apply for Coverage


Loss of Minimum Essential Coverage or Federal Program Eligibility

A loss of coverage due to nonpayment of premium, fraud, or misrepresentation shall not be a triggering event unless it was committed by the employer.

Eligible Effective Date:

First day of the month following enrollment

Event Documentation

Legal Separation


Legal documentation


Divorce


Divorce decree


Child Loses Dependent Status


Proof of loss of dependent status

May include a dependent child reaching age 26, divorce, separation, or death.

  • Letter from carrier with termination notification
  • Birth certificate
  • Driver's license
  • State ID
  • Passport

Death of an Employee or Policyholder


Death certificate
Termination of Employment

Letter from employer on employer letterhead explaining why coverage was terminated.

If a letter from the employer cannot be provided, submit official documentation from unemployment along with reason for termination.


Reduction in the Number of Employment Hours

Letter from employer on employer letterhead explaining why coverage was terminated.


No Longer Reside in the Service Area

Individual Market

  • Proof that you no longer reside in the service area
  • Letter from carrier stating that you moved outside of their service area and were terminated
  • Evidence of new address, such as a utility bill

Group Market

  • Proof that you no longer reside in the service area
  • Letter from employer on employer letterhead stating that no other benefit package is available to you

Similarly Situated Job Classification

Letter from employer on employer letterhead


Your Marketplace Plan Lost its Certification

Letter from the carrier or Marketplace


Contribution Stopped by Employer

Letter from employer on employer letterhead


Exhaustion of COBRA continuation coverage

Proof that the full COBRA coverage expired


Loss of Noncalednar Year Coverage/Policy Expiration

Letter from employer on employer letterhead



Gaining or Becoming a Dependent

Gaining or becoming a dependent through Marriage, Birth, Adoption, Placement for Adoption, Placement in Foster Care, or through a Child Support Order or other court order.

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.

Eligible Effective Date:

The date of birth, adoption, or placement for adoption

Event
Documentation
Marriage (includes same sex spouses)
Copy of marriage license
Common Law Marriage (from another state)
  • A joint notarized statement indicating that the common law marriage exists
  • The name of the state in which the common law marriage was recognized
  • The date the couple met the state's definition of common law partners
    • Proof of joint bank account
    • Joint deed
    • Mortgage
    • Lease
    • Joint tax return

Civil Union Partner
Copy of the civil union license/certificate
Domestic Partner
Copy of certificate of domestic partnership
Birth
Birth certificate
Child Placed For Adoption, Legally Adopted, Child Support Order or Other Court Order
  • A copy of the adopted child's birth certificate in the name of the adopting parent(s) together with a certificate by the parent(s) of the date of adoption
  • A notarized statement by a state-approved and accredited adoption agency stating that adoption proceedings have been initiated in a court of competent jurisdiction and that the name of the child has been formally placed for adoption with the prospective parent(s) who are also named on the statement

Or

  • A notarized legal document from the attorney representing the policyholder, which clearly defines the parties involved and the terms of the custody appointment. The document should include a statement indicating that the policyholder is responsible for the medical care of the child

Child Placed In Foster Care

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


Permanent Move To Capital BlueCross Service Area

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.

Eligible Effective Date:

First day of the month following enrollment

Event Documentation
Move to Pennsylvania
  • Date of the move from another state or country
  • Proof of residence in another state or country
  • Proof of residence in our 21-county service area
  • Proof of previous minimum essential coverage

Proof of residence includes one of the following:

  • Driver's license
  • Car registration
  • Automobile insurance policy
  • Deed
  • Income tax return
  • Utility bill
  • Lease
  • Homeowner's/renter's insurance policy


Change On-Marketplace Coverage

Eligible Effective Date:

First day of the month following enrollment

Event Documentation
Loss of Advance Premium Tax Credit (APTC) or Cost Sharing
Documentation from the Marketplace


Enrollment or Plan Error

Eligible Effective Date:

First day of the month following enrollment

Event 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 officer, or employee of Capital BlueCross, providing enrollment assistance or conducting enrollment activities. Applies to the contractholder or dependents on the plan.

Plan Contract Violation

Documentation that displays the violation

The contractholder or dependent 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

This is a valid Special Enrollment event, if the application to Medicaid or CHIP occurred during the Open Enrollment Period, or a Special Enrollment Period and the denial was received after the close of those periods.

Proof of the original application date



Domestic Abuse or Spousal Abandonment

Eligible Effective Date:

First day of the month following enrollment

Event Documentation
Domestic Abuse or Spousal Abandonment

Proof of prior coverage with perpetrator

Can be any document that includes a list of covered members.

Self-attestation stating they are a victim of domestic abuse or spousal abandonment