Exceptional Circumstance Special Enrollment Period Request Form

This form is to be used to request an Exceptional Circumstances Special Enrollment Period (SEP).  This SEP is intended for specific circumstances that prevented you from enrolling during either the annual open enrollment period or another SEP, including:

  • A medical condition
  • A natural disaster
  • A system interruption 

This Exceptional Circumstance SEP Request Form should only be submitted after you have completed an application for health coverage with VHC.  If you have not completed an application yet you can do so online or by calling customer service at 1-855-899-9600.

If you are applying for the Exceptional Circumstance SEP due to a Medical Issue, we must receive a completed Medical Incapacity Verification Form before your eligibility can be determined. Please have your doctor complete the form below and return it to the address on the form.
 

Medical Incapacity Verification Form 

 

An individual should apply for the Exceptional Circumstance Special Enrollment Period (SEP) only if an event such as a medical issue, natural disaster, or a system interruption prevented them from enrolling in a QHP during the Annual Open Enrollment or during a SEP the individual was eligible for that has now expired.  Please review the examples provided below for additional clarification.

Example #1

An individual qualified for a Special Enrollment Period that expired March 31st.  The individual was in the hospital from March 14th to April 1st and was unable to enroll in a QHP at that time.  This individual should complete this application as well as the medical incapacity verification form as they may be eligible for the Exceptional Circumstance SEP.

Example #2

An individual qualified for a Special Enrollment that expired May 31st.   The individual got sick in July after their original SEP expired and now needs health coverage.  The individual should not complete this form as they were not medically incapacitated (sick) during their original Special Enrollment Period and not prevented from enrolling prior to May 31st, therefore would not qualify for the Exceptional Circumstance SEP.

 

What’s next?

  1. Submit this form.
  2. Complete the Medical Incapacity Verification Form if you are requesting the Exceptional Circumstance SEP due to a Medical Issue.
  3. Your request will be reviewed, and you will receive a response within 15 days.
For example: if you were medically incapacitated as of 2/15/2019, that would be the start date. If you were released from the hospital as of 3/1/2019, that would be your end date.