BCBS Individual Under 65 Health SEP Eligibility

SEP Qualifying Event*

I and/or my dependent(s) lost Minimum Essential Coverage
I gained or became a dependent due to marriage on:
I gained or became a dependent due to birth, adoption, or placement for adoption or foster care on:
An error occurred in my previous health plan enrollment, or I have adequately demonstrated that my previous health plan or issuer substantially violated a material provision of its contract with me, as of:
The Health Insurance Marketplace has determined that I or my dependents am/are newly eligible or ineligible for payments of the advanced premium tax credit, or have a change in cost-sharing eligibility, or misconduct by a non-Marketplace entity as of:
I gained access to new health plan options because of a permanent move on:
My current policy is ending on a non-calendar year date (a date other than December 31st), which is:

Please Specify Event Details*

Involuntary loss due to reasons other than non-payment of premium or rescission on:
Due to reaching the maximum age, legal separation, divorce, or death of the policyholder, as of:
I am no longer eligible for my prior health insurance plan due to termination of employment, reduction in number of hours of employment or loss of employer contribution toward my premiums, or I have exhausted my COBRA benefits as of:
I am no longer residing or living in my prior health insurance plan’s HMO service area as of:
I have a claim that would meet or exceed a lifetime limit on all benefits as of:
I have lost coverage because my plan no longer offers benefits to the class of similarly situated individuals as of:
I have lost coverage through my group HMO because I no longer reside or work in the service area and no other package is available as of:

Please Specify Event of Policyholder*

Reaching The Maxium Age of 26
Legal Separation
Divorce
Death of the policy holder

Please Specify New Dependent Due To Marriage*

Marriage
Domestic Partner
Civil Union

Please Specify New Dependent*

Birth
Adoption (or) Placement For Adoption
Foster Care
Court Ordered Dependent Coverage

Documentation Needed Before Applying

Letter from prior insurer or employer with coverage termination date on company letterhead
Discontinuation notice
COBRA notice
State continuation notice

Letter from employer confirming loss of contributions
A letter from employer on company letterhead and signed by an officer/owner of the company indicating reduction in hours and loss of coverage along with pay stubs confirming reduction in hours

Certificate of Creditable Coverage
COBRA “Termination of Coverage” letter from insurer

“Termination of Coverage” letter from existing/prior insurer indicating dependent is not an eligible dependent

(OR)

Proof of prior coverage AND one of the following:

Birth certificate
Driver’s license
State ID
Military ID
Passport

- Court-issued legal separation document including date of separation, judge's signature and member's name
- Court-issued divorce decree including date of divorce, judge's signature and member's name
- Notarized Domestic Partner Termination form
- Death Certificate
- Obituary
1. Marriage license or certificate
1. Domestic partner affidavit
1. Civil union license or certificate
1. Birth Certificate
2. Proof of live birth from a hospital
1. Birth certificate that includes the name of the adopting parent
2. A certificate with the date of adoption
3. Court documents showing placement for adoption
4. A notarized statement by the adoption agency that adoption proceedings have been initiated and that the child has been placed for adoption
1. Court document from the authorizing agency showing responsibility for foster care
1. Court documents showing court-ordered dependent coverage
1. Letter from the Federal Marketplace on letterhead
2. Letter from insurer on letterhead
1. Letter from the Federal Marketplace on letterhead
ONE of the following:
- Driver’s license
- State ID
- Utility bill
- Property tax bill
- Rental, lease or mortgage agreement
- Vehicle registration
- USPS “change of address” receipt or documentation
AND
- Either proof of at least one day of minimum essential coverage in the past 60 days before the permanent move or has lived outside the US (or a US territory) at the time of the permanent move
- Discontinuation notice
- State continuation notice
- COBRA notice
- Letter from other insurer on insurer letterhead
- Carrier coverage cancellation notice or certificate of creditable coverage
- Renewal letter from carrier or written verification from producer/agent
Documentation must show that the applicant had coverage for one or more of the 60 days prior to the move and that the permanent move occurred within 60 calendar days of application submission AND one of the following:
Chain Select

Individual SEP Eligibility

Documentation Needed Before Applying