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Enrollment Periods: Individuals & Families

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Enrollment Periods: Individuals & Families

All the details you need on when you can choose a health plan for yourself and your family: Open Enrollment, Special Enrollment Period, Qualifying Life event.

Open Enrollment is a time period every year when individuals and families can enroll in health insurance or change their coverage. Open Enrollment usually starts on November 1^st and ends on January 31^st ; if you are not able to complete your enrollment during that time, you might still be able to get coverage, if you meet the conditions for a Special Enrollment Period.

Outside of the yearly Open Enrollment Period, there are major life changes or special circumstances that enable you to be eligible for a Special Enrollment Period (SEP). The SEP provides a 60-day window when you can enroll or change your health plan. If you miss that window, you may have to wait until the next Open Enrollment period for a chance to apply for coverage. If you are losing coverage, you can apply for a new plan as early as 60 days before your current insurance will end to avoid a potential gap in coverage.

If you experience a major change in your life, it could affect your coverage; these changes may include: marriage, birth, unemployment…etc., and are usually called Qualifying Life Events (QLE). When applying for coverage with a qualifying life event, you may be required to provide supporting documentation for your event; for example, a copy of your marriage certificate would be required when adding a spouse to your plan. There are different types of qualifying life events requiring different types of supporting documentation; continue below to learn more.

Types of Qualifying Events

Loss of Minimum Essential Coverage (MEC)

Loss of eligibility for Medicaid, Medicare, or CHIP
Loss of Employer Group Coverage
- Employee is no longer eligible due to termination, a reduction of hours, or end of Cobra coverage.
- A dependent loses coverage due to the passing of the subscriber (covered employee).
- Employee becomes eligible for Medicare.
- Employer no longer offers health coverage.
For individuals who have lost their coverage for reasons other than:
- failure to pay their monthly premiums
- providing false information on a previous enrollment
- voluntarily ending their coverage

Minimum Essential Coverage refers to any insurance plan that provides essential health benefits, has standard limits on cost-sharing (like deductibles, copayments, and out-of-pocket maximum amounts), and meets other requirements under the Affordable Care Act. Examples of plans that qualify include: Marketplace plans, job-based plans, Medicare, Medicaid, and Children's Health Insurance Program (CHIP).

Supporting Documentation: Choose the specific document that applies to you from the list below.

Signed letter from the previous insurer or employer on company letterhead stating why you lost your coverage.
COBRA eligibility letter on company letterhead.
Copy of the subscriber’s death certificate.
For Medicare eligibility: Copy of letter from CMS stating that you are eligible for Medicare.
Signed Letter from employer on company letterhead stating they no longer offer coverage as of a specific date.
Signed letter from the administrator (insurance carrier) stating that COBRA benefit has been fully exhausted.

Addition or Change in Dependent Status

Marriage – adding a spouse or partner.
Adding a dependent through childbirth, adoption, foster care, or court order (including child support).
End of dependent status due to age (dependent turned 26 and no longer qualifies under parent’s coverage), divorce, or legal separation.

Supporting Documentation: Choose the specific document that applies to you from the list below.

Copy of the marriage certificate.
Copy of the birth certificate, court document, or court order.
Copy of the divorce decree or legal separation court order.
Letter from employer or previous insurer stating loss of dependent status.

Change in Residence

Moving to a different state, city, ZIP code or county.
Moving into EmblemHealth’s service area.
Moving to or from a shelter, or other transitional housing.

Supporting Documentation:

Signed letter from the administrator of previous insurer AND the official change of address confirmation letter from the post office, a utility bill, or a credit card statement, showing your new address.

Other Qualifying Events

Change in your income that impact the coverage you qualify for.
Eligibility for advanced premium tax credits (APTC) or cost sharing reductions.
Eligibility through citizenship or lawfully present status.
Gaining membership in a federally recognized tribe or status as an Alaska Native Claims Settlement Act (ANCSA) Corporation shareholder.
Leaving incarceration (released from jail or prison).
AmeriCorps member starting or ending your service.
Error in enrollment.
You are a victim of domestic abuse or spousal abandonment.
You are a victim of a natural disaster or you’ve experienced an exceptional circumstance, such as being incapacitated.
Your previous or current plan/insurer violated a material provision of your enrollment contract.
Pregnancy – up to 30 days after its commencement as certified by a licensed health care provider.

Supporting Documentation:

Copy of legal incarceration release letter.
For Pregnancy: Written certification up to 30 days after the commencement of the pregnancy, by a licensed health care provider.
Letter from the other carrier stating the details of the provision violation of your enrollment contract.
Signed letter on company letterhead from the entity (employer, previous insurance carrier or Marketplace) that committed the enrollment error.
Copy of the eligibility determination from the State Exchange.

If you have any questions, or you’re not sure which option applies to you, call us at 877-411-3625. A representative will be happy to assist you.

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Any information provided on this Website is for informational purposes only. It is not medical advice and should not be substituted for regular consultation with your health care provider. If you have any concerns about your health, please contact your health care provider's office.

Also, this information is not intended to imply that services or treatments described in the information are covered benefits under your plan. Please refer to your Membership Agreement, Certificate of Coverage, Benefit Summary, or other plan documents for specific information about your benefits coverage.