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West Virginia's Health Insurance Helpline

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West Virginia's Health Insurance Helpline

Special Enrollment Periods

A Special Enrollment Period may let you enroll in health coverage outside of the annual Open Enrollment Period if you experience certain situations, or during Open Enrollment for an earlier coverage start date. You may qualify for a Special Enrollment Period through the Health Insurance Marketplace in these situations: 

1. Loss of qualifying health coverage 

You may qualify for a Special Enrollment Period if you (or anyone in your household) lost qualifying health coverage (or “minimum essential coverage”). Some examples of qualifying coverage include:

  • Coverage through a job, or through another person’s job. This also applies if you’re now eligible for help paying for coverage because your employer stops offering coverage or the coverage isn’t considered qualifying coverage.
  • Medicaid or Children’s Health Insurance Program (CHIP) coverage (including pregnancy-related coverage and medically needy coverage).
  • Medicare.
  • Individual or group health plan coverage that ends during the year.
  • Coverage under your parent’s health plan (if you’re on it). If you turn 26 and lose coverage, you can qualify for this Special Enrollment Period.

Note: This doesn’t include loss of coverage because you didn’t pay your premiums or if your coverage was taken away because of fraud or intentional misrepresentation.

More information

Available in advance:
You may report a loss of qualifying health coverage up to 60 days before the loss of coverage.

Special Enrollment Period confirmation:
If you’re enrolling in Marketplace coverage for the first time, you may need to submit documents to prove you qualify for this Special Enrollment Period. 


2. Change in household size

You may qualify for a Special Enrollment Period if you (or anyone in your household):

  • Got married
  • Had a baby, adopted a child, or placed a child for foster care
  • Gained or became a dependent due to a child support or other court order

Note: If you gained or became a dependent due to marriage, then one spouse must have also had qualifying health coverage for one or more days in the 60 days prior to the marriage. This doesn’t apply if the spouse was living in a foreign country or a U.S. territory for one or more days in the 60 days prior to the marriage, or is a member of a federally recognized tribe or a shareholder in an Alaska Native Corporation.

More information

Special Enrollment Period confirmation:
If you’re enrolling in Marketplace coverage for the first time, you may need to submit documents to prove you qualify for a Special Enrollment Period due to a marriage or due to an adoption, foster care placement, or child support or other court order. 


3. Change in primary place of living 

You may qualify for a Special Enrollment Period if you (or anyone in your household) have a change in your primary place of living and gain access to new Marketplace health plans as a result. Household moves that qualify you for a Special Enrollment Period include:

  • Moving to a new home in a new ZIP code or county
  • Moving to the U.S. from a foreign country or U.S. territory
  • A student moving to or from the place he or she attends school
  • A seasonal worker moving to or from the place he or she lives and works
  • Moving to or from a shelter or other transitional housing

Note: You qualify only if you had qualifying health coverage for one or more days in the 60 days prior to your move. This doesn’t apply if you were living in a foreign country or a U.S. territory for one or more days in the 60 days prior to the move, or if you’re a member of a federally recognized tribe or a shareholder in an Alaska Native Corporation. Moving only for medical treatment or staying somewhere for vacation doesn’t qualify you for a Special Enrollment Period.

More information

Special Enrollment Period confirmation:
If you’re enrolling in Marketplace coverage for the first time, you may need to submit documents to prove you qualify for this Special Enrollment Period. 


4. Change in eligibility for Marketplace coverage or help paying for coverage 

You may qualify for a Special Enrollment Period if you (or anyone in your household):

  • Are enrolled in Marketplace coverage and report a change that makes you:
    • Newly eligible for help paying for coverage.
    • Newly ineligible for help paying for coverage.
    • Eligible for a different amount of help paying for out-of-pocket costs, like copayments.
  • Become newly eligible for Marketplace coverage because you’ve become a citizen, national, or lawfully present individual.
  • Become newly eligible for Marketplace coverage after being released from incarceration (detention, jail, or prison).
  • Gain or maintain status as a member of a federally recognized tribe or Alaska Native Claim Settlement Act (ANCSA) Corporation shareholders (a status that lets you change plans once per month, and lets your dependents enroll in or change plans with you).
  • Become newly eligible for help paying for Marketplace coverage because you moved to a different state and you were previously both of these:
    • Ineligible for Medicaid coverage because you lived in a state that hasn’t expanded Medicaid.
    • Ineligible for help paying for coverage because your household income was below 100% of the Federal Poverty Level (FPL). 

5. Enrollment or plan error

You may qualify for a Special Enrollment Period if you (or anyone in your household):

  • Weren’t enrolled in a plan or were enrolled in the wrong plan because of:
    • Misinformation, misrepresentation, misconduct, or inaction of someone working in an official capacity to help you enroll (like an insurance company, navigator, certified application counselor, agent or broker).
    • A technical error or other Marketplace-related enrollment delay.
    • Wrong plan data (like benefit or cost-sharing information) displayed on HealthCare.gov at the time that you chose your health plan.
  • Can prove your Marketplace plan violated a material provision of its contract. 

6. Other situations 

You may qualify for a Special Enrollment Period if you (or anyone in your household):

  • Applied for Medicaid or Children’s Health Insurance Program (CHIP) coverage during the Marketplace Open Enrollment Period, or after a qualifying event, and your state Medicaid or CHIP agency determined you (or anyone in your household) weren’t eligible.
  • Are a victim of domestic abuse or spousal abandonment and want to enroll yourself and any dependents in a health plan separate from your abuser or abandoner.
  • Submitted documents to clear your data matching issue after your coverage ended.
  • Are under 100% of the Federal Poverty Level (FPL), submitted documents to prove that you have an eligible immigration status, and didn’t enroll in coverage while you waited for your documents to be reviewed.
  • Are an AmeriCorps service member starting or ending AmeriCorps service.  
  • Can show you had an exceptional circumstance that kept you from enrolling in coverage, like being incapacitated or a victim of a natural disaster.
  • More information

Special Enrollment Period confirmation:
If you’re enrolling in Marketplace coverage for the rst time, you may need to submit documents to prove you qualify for a Special Enrollment Period due to a denial of Medicaid or CHIP coverage. 


What if I think I qualify for a Special Enrollment Period?

Call us at 1-844-WV-CARES to answer a few questions and find out if you qualify for a Special Enrollment Period. If you’re eligible, you’ll also find out if you’re eligible for coverage through Medicaid or the Children’s Health Insurance Program (CHIP) when you apply. We’ll tell you when your coverage will start and your next steps.

Important: When you apply, you must attest that the information you provide on the application is true, including the facts that qualify you for a Special Enrollment Period.

What if the Marketplace needs documents to confirm my Special Enrollment Period?

When you apply for Marketplace coverage and qualify for a Special Enrollment Period, if you’re newly enrolling in Marketplace coverage, you may be asked to provide documents to confirm the events that make you eligible. You must send the document copies (don’t send originals) before you can make your first payment and start using your coverage.

After you submit your application, you’ll learn if you have to provide documents. Details and instructions appear on your eligibility results screen and in a notice you can download or get in the mail.

It’s best to pick a plan first and submit your documents afterwards. After you pick a plan, you have 30 days to send the documents.

Your coverage start date is based on when you pick a plan. But you can’t use your coverage until your Special Enrollment Period eligibility is confirmed and you make your first premium payment.

If your eligibility results don’t say you need to provide documents, you don’t have to. Simply pick a plan and enroll. For more information, call us now at 1-844-WV-CARES.