Eleanor Finch
A qualifying event for health insurance is a significant change in an individual's life situation that allows them to adjust their health insurance plan outside of the standard annual Open Enrollment Period. These events typically include circumstances that may impact an individual's current health insurance coverage and necessitate enrolling in a new plan. This could include losing health insurance coverage, gaining or losing a dependent, changes in residence, and changes in employment status. During a qualifying life event, individuals are usually given a Special Enrollment Period (SEP) of 30 to 60 days before or after the event to make changes to their health plan or sign up for a new one.
| Characteristics | Values |
|---|---|
| Loss of health insurance coverage | Losing job-based coverage, COBRA, or a student plan, turning 26 and losing coverage through a parent's insurance plan, losing eligibility for Medicare, Medicaid, or the Children's Health Insurance Program (CHIP) |
| Change in residence | Moving to a different zip code, county, or state that changes your health plan area, moving to the US from a US territory or foreign country |
| Change in employment status | Laid off, dismissed, resigned, quit, retired, furlough |
| Household changes | Death of someone on your insurance policy, gaining or losing a dependent, marriage, divorce |
| Documentation | Birth certificates, adoption records, marriage licenses, divorce paperwork, death certificates, new rental agreements, deeds, or mortgages |
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What You'll Learn
Loss of health insurance coverage
However, it is important to note that if you lose your job-based health coverage because you voluntarily dropped it during the plan year or lost your coverage because you didn't pay your premium, you will not qualify for a Special Enrollment Period (SEP). Similarly, loss of coverage due to rescission does not count as a qualifying life event. Rescission is still used by short-term health insurance plans, and the termination of a short-term plan for any reason does not trigger an SEP in the individual market.
If you lose your health insurance, you may qualify for an SEP, allowing you to apply for essential health insurance coverage 60 days before or after a qualifying life event. This includes losing Medicaid or Children's Health Insurance Program (CHIP) coverage, which can occur if you lose health coverage through your employer or the employer of a family member. For example, a person who is covered as a dependent on an employer-sponsored plan would lose access to the plan if the employee were to die.
In addition to the loss of health insurance coverage, other qualifying life events include changes in your household, such as gaining a dependent through birth or adoption, or changes in your residence, such as relocating to a different zip code, county, or state that changes your health plan area.
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Change in residence
Moving to a new location can impact your insurance options and is considered a qualifying life event for health insurance. This may include moving to a different zip code, county, or state that changes your health plan area. For example, you may be relocating to an area where your current coverage is unavailable, or there may be new plans to consider in your new location.
If you have recently moved, it is important to contact your insurer to understand your options and avoid a coverage gap. You may be asked to provide documentation to confirm your change in residence, such as new rental agreements, deeds, or mortgages.
If you are moving for work, a letter from your employer confirming your relocation may be required. If you are moving to the U.S. from another country, you may need to provide a green card, education certificate, or visa.
In some cases, a change in residence may qualify you for a Special Enrollment Period (SEP), allowing you to apply for new health insurance coverage or change your existing plan outside of the standard Open Enrollment Period. This period typically allows you to make changes to your health insurance plan within 60 days leading up to or following a qualifying life event.
It is always best to plan ahead and contact your health insurance provider or the Marketplace to understand your options and any specific requirements or documentation that may be necessary for eligibility.
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Change in employment status
A change in employment status is a qualifying life event that can impact your health insurance and other employee benefits. This includes both voluntary and involuntary changes, such as being laid off, dismissed, resigning, quitting, or retiring. Losing your job-based coverage is a qualifying life event, but it does not mean you have to lose your health coverage. You may qualify for a Special Enrollment Period (SEP) to apply for essential health insurance coverage within 30 to 60 days before or after the qualifying life event.
During a Special Enrollment Period, you can enroll in a new health plan or change your existing plan outside of the annual open enrollment period. Losing job-based coverage, COBRA, or a student plan are all considered qualifying life events that can trigger an SEP. Additionally, if you are asked to renew or recertify your Medicaid coverage and lose it in the process, you may also qualify for an SEP.
It is important to note that your spouse's change in employment status is only considered a qualifying life event if it results in a loss of insurance for you or your spouse. A furlough can also be a qualifying life event if it leads to a loss of eligibility or if your employer drops your coverage. However, if your employer maintains your eligibility and coverage during the leave, it does not qualify.
If you anticipate a qualifying life event, it is recommended to contact your insurer or the Marketplace in advance to avoid a coverage gap. You may be required to provide documentation of your qualifying life event, such as letters from your employer regarding relocation or proof of prior coverage.
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Marriage, divorce, or parenthood
Marriage, divorce, and parenthood are all major life events that qualify an individual to immediately buy or make changes to a health plan. These events can include gaining a dependent through birth or adoption, or becoming a dependent yourself. For example, a child may gain dependency on their parent's insurance after turning 26 and losing coverage through their own plan.
When enrolling in a plan, you may be required to provide documentation of your qualifying life event. This could include birth certificates, adoption records, and marriage licenses that show you have added family members and need to modify your health insurance coverage. Divorce paperwork may also be required to show that a family member who previously provided you with health insurance coverage is no longer doing so.
A special enrollment period (SEP) is generally triggered by a qualifying life event, during which an individual is allowed to make plan changes or sign up for a new health insurance plan immediately. A special enrollment period generally lasts 30–60 days before or after the qualifying life event. During this time, you may qualify for short-term insurance to bridge the gap and ensure you are not without insurance at any point.
It is important to note that the specific requirements and documentation needed for a qualifying life event may vary depending on your location and insurance provider. Therefore, it is always best to contact your insurer or the relevant authority to understand your options and what documents are necessary for eligibility.
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Death of a family member
The death of a family member is a qualifying life event that can impact your health insurance coverage and make it necessary to enroll in a new plan. This is especially true if the deceased was the primary holder of your family's health insurance policy, or if their income contributed to insurance coverage.
If you were covered under your loved one's plan, you will need to take steps to ensure continued coverage or obtain alternative coverage. Contact your insurer or the Marketplace as soon as possible after the event to understand your coverage options. You may be required to provide documentation, such as a death certificate, to prove the qualifying life event.
If your loved one was covered under your plan, you may also need to make some alterations. If they were covered by Medicare, you will need to inform the relevant bodies so that premium and other billing for coverage can stop. If you received health care benefits as part of your spouse's retirement package, your coverage may be affected, and you should check with the plan administrator for details.
With most employer-sponsored plans, surviving dependents have the option of COBRA medical insurance. This program, named after The Consolidated Omnibus Budget Reconciliation Act, allows dependents to extend their current coverage for up to 36 months. However, COBRA can be expensive, as you will be paying the full premium cost, including the portion previously paid by the employer.
If you already have an exchange-based plan, the death of your loved one may qualify you for a Special Enrollment Period (SEP) to change plans. You may also find that the loss of a family member's income qualifies you for government-sponsored premium subsidies or cost-sharing programs available for exchange plan members.
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Frequently asked questions
A qualifying event for health insurance is a significant change in your life circumstances that allows you to adjust your health insurance plan.
Qualifying events include getting married, having a baby, turning 26, losing your job, and moving to a different location that impacts your insurance options.
You typically have a special enrollment period (SEP) of 30 to 60 days before or after the qualifying event to make changes or sign up for a new plan.
The documentation required depends on the specific qualifying event. Common documents include birth certificates, marriage licenses, divorce paperwork, and proof of previous or upcoming loss of coverage.
Contact your insurer or the Marketplace as soon as possible after the qualifying event to understand your options and eligibility. They will guide you through the specific requirements and next steps.
