CurrentMedicarePolicy N/A

Emergency and Major Disaster Declarations by FEMA - Special Enrollment Periods (SEPs), Termination, and Payment Deadline Flexibilities

Guidance for Federally-facilitated Exchange (FFE) QHP and stand-alone dental issuers on Special Enrollment Periods (SEPs), termination, payment deadline flexibilities, and enforcement discretion when FEMA declares emergencies or major disasters, affecting consumers and issuers.

Policy Summary

PayerMedicare

PolicyEmergency and Major Disaster Declarations by FEMA - Special Enrollment Periods (SEPs), Termination, and Payment Deadline Flexibilities

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateAug 9, 2018

Next Review DateN/A

Key ActionContact the Marketplace Call Center (1-800-318-2596 or TTY 1-855-889-4325) to request an Exceptional Circumstances SEP and indicate inability to enroll due to a FEMA-designated emergency or disaster.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

60 daystimeframe to select a QHP after FEMA incident period ends

1-800-318-2596Marketplace Call Center for SEP requests

45 CFR §155.420(d)(9)regulatory citation authorizing Exceptional Circumstances SEP

Tax Cuts and Jobs Actrelated tax law

Exceptional Circumstances SEP — Eligibility & Effective Dates

Policy Summary

PayerMedicare

PolicyEmergency and Major Disaster Declarations by FEMA - Special Enrollment Periods (SEPs), Termination, and Payment Deadline Flexibilities

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateAug 9, 2018

Next Review DateN/A

SourceLink

On This Page

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Exceptional Circumstances SEP criteria and related flexibilities

Covered when ALL of the following are met:

Individual attests they were unable to enroll in an enrollment period for which they were eligible (Open Enrollment Period or a Special Enrollment Period) because of a FEMA-declared emergency or major disaster.

Individual resided in any county that was eligible to apply for FEMA individual assistance or public assistance either during the FEMA-designated incident period or at the time of application for enrollment.

Individual attests they were affected by the emergency or disaster and that it prevented them from completing enrollment.

Timing: Individual applies within 60 days from the end of the FEMA-designated incident period to select a QHP through the FFE or make changes to an existing QHP enrollment.

Effective date options: Individual may choose a future coverage effective date pursuant to 155.420(b)(1), or request an effective date that would have applied during the original enrollment opportunity on or after the FEMA incident start date (examples and tables of sample effective dates are provided).

Other considerations

Individuals impacted by disasters that do not have FEMA declarations may be considered individually for Exceptional Circumstances SEPs.
Coverage effective date rules vary based on the date of plan selection and the qualifying event; see sample scenarios for retroactive and future effective date options.

How to Request & Expedite an SEP

Prior Authorization

How to request an Exceptional Circumstances SEP

Contact the Marketplace Call Center at 1-800-318-2596 (TTY 1-855-889-4325) and state that you were eligible for another enrollment window but were unable to complete enrollment due to a FEMA-designated emergency or disaster. After the request, a caseworker will re-evaluate the SEP eligibility using Marketplace records and FEMA public declarations; you will be notified of the determination by mail and can select a plan once approved.

Call Marketplace Call Center: 1-800-318-2596 or TTY 1-855-889-4325.
Tell the representative you were eligible for an enrollment window but could not complete enrollment because of a FEMA-designated emergency or disaster.
A caseworker will re-evaluate the request using Marketplace records and FEMA declarations; notification is by mail.

Documentation Required

Expedited SEP application guidance

To expedite processing, complete an application on HealthCare.gov before calling the Marketplace Call Center — you may do this directly or with help from a Navigator, Agent/Broker, Certified Application Counselor, or Direct Enrollment Partner. Note that initial eligibility results may show ineligibility; each SEP request will be re-evaluated by a caseworker and may take several days.

Complete an application on HealthCare.gov in advance (self or with authorized assister).
Expect initial eligibility to possibly show OEP/SEP has ended; wait for caseworker re-evaluation.
SEP determination is made using Marketplace consumer records and public FEMA declarations and will be mailed.

Who Qualifies as Affected by the FEMA Incident

FEMA-emergency affected (definition and key rules)

DefinitionIndividuals who resided in counties eligible for FEMA individual or public assistance during the FEMA-designated incident period or at application time and who were affected such that they could not complete enrollment.

Attestation requirementMust attest they were affected by the FEMA-declared emergency or major disaster and that it prevented completion of enrollment.

Timeframe to enrollEligible for up to 60 days from the end of the FEMA-designated incident period to select a QHP or change an existing enrollment.

Effective date optionsMay choose a future coverage start per 45 CFR §155.420(b)(1) or request the effective date that would have applied if they had selected a plan during the original enrollment opportunity on or after the FEMA incident start date.

Source for FEMA declarationsFEMA declarations of emergency and major disasters are listed at https://www.fema.gov/disasters.

OpenPayer

Emergency and Major Disaster Declarations by FEMA - Special Enrollment Periods (SEPs), Termination, and Payment Deadline Flexibilities

Exceptional Circumstances SEP — Eligibility & Effective Dates

Regulatory Basis / Citation

How to Request & Expedite an SEP

Who Qualifies as Affected by the FEMA Incident