Simone Lawson
Losing your health insurance coverage is a qualifying life event that allows you to enroll in a new health insurance plan outside the Open Enrollment Period. This is known as a Special Enrollment Period (SEP). However, it is important to note that not all types of loss of coverage constitute a qualifying life event. For instance, if you voluntarily drop your coverage or lose your coverage due to non-payment of premiums, you will not qualify for an SEP. On the other hand, if you lose your coverage due to circumstances beyond your control, such as losing your job and your employer-sponsored health insurance, you will likely qualify for an SEP.
| Characteristics | Values |
|---|---|
| Qualifying life events | Losing health coverage, moving, getting married, having a baby, or adopting a child |
| Loss of coverage events | Losing health insurance, losing employer-sponsored coverage, losing Medicaid or CHIP coverage, losing individual health coverage |
| Qualifying for SEP | Losing health coverage in the past 60 days or expecting to lose coverage in the next 60 days, losing Medicaid or CHIP coverage in the past 90 days |
| Documentation required | Birth certificates, adoption records, marriage licenses, divorce paperwork, death certificates, rental agreements, deeds, mortgages, U.S. Postal Service change of address confirmation, school documentation, letter from employer |
| Special circumstances | Gaining membership in a federally recognized tribe, becoming a U.S. citizen, starting or ending service in AmeriCorps, experiencing an unexpected natural disaster |
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What You'll Learn
Losing job-based health coverage
Your special enrollment period begins 60 days before your employer-sponsored policy ends and continues for another 60 days after the plan ends, even if you had the option to extend your coverage by using COBRA. This means that you will have a full 120-day special enrollment period to choose and enrol in a new plan. During this time, you can also choose to elect COBRA or other continuation coverage available to you.
It is important to note that you will not qualify for an SEP if you voluntarily dropped your job-based health coverage during the plan year or lost your coverage because you did not pay your premium. If you decide to end your COBRA coverage early, you will also not qualify for a special enrollment period. However, exhausting your COBRA coverage does trigger a special open enrollment window, as it counts as a loss of other coverage.
To enrol in a new plan during the Special Enrollment Period, you may need to verify your qualifying life event through documentation. This could include providing documentation such as divorce paperwork, birth certificates, adoption records, or proof of a change in residence.
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Insurer exits the market
If your insurer exits the market, you may qualify for a Special Enrollment Period (SEP). This is a period during which you can purchase a new health insurance plan outside of the regular annual ACA open enrollment period.
In most circumstances, you will have 60 days following your qualifying life event to choose and enroll in a new policy. This period may begin 60 days before your current policy ends and continue for another 60 days after the end date. In some cases, you may have a special enrollment window that begins 60 days before the event and continues for 60 days after it. In most cases, the coverage will be effective on the first of the month following your enrollment date. However, if the qualifying event is the birth or adoption of a child, the coverage can be backdated to the date of the birth or adoption.
To enroll in a new plan, you may need to verify your qualifying life event through documentation. You will find out if you need to provide documentation before submitting your application for coverage. In some cases, you may not need to provide anything. However, if you are asked, HealthCare.gov advises you to pick a policy first and submit documentation afterward. Once you choose a policy, you will have 30 days to submit the verifying documents. Details and instructions on the type of documents you need to submit will appear on your eligibility results screen and in a notice you can download or receive in the mail.
If you do not meet the qualifications for an SEP, you still have options for coverage. For example, you may be eligible to enroll in Medicaid. Medicaid is a government-run health insurance program that provides coverage for millions of individuals and families who meet certain income and other eligibility requirements. It is designed to provide health plans for low-income individuals, children, pregnant women, and people with disabilities. You do not need to experience a qualifying life event to apply for and enroll in Medicaid.
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Exhausting COBRA
COBRA coverage can be continued for a minimum of 18 to 36 months, depending on the circumstances. Once this allowable continuation window ends, individuals are considered to have exhausted their COBRA coverage. It is important to note that voluntarily ending COBRA coverage early, such as by failing to pay premiums or committing fraud, does not qualify as a qualifying life event.
When COBRA coverage is exhausted, individuals may qualify for individual health insurance coverage as "HIPAA-eligible individuals." This allows them to purchase individual health coverage without an exclusion period for pre-existing medical conditions. To ensure continuous coverage, it is recommended to contact the relevant state department of insurance before COBRA coverage ends.
Additionally, when COBRA coverage is exhausted, some options that were available before electing COBRA may still be available. For example, individuals may have the opportunity to "convert" to an individual health insurance policy instead of continuing with group coverage. This option must be provided by the plan, and individuals have the right to exercise it within 180 days before their COBRA coverage ends.
After exhausting COBRA, individuals typically have 60 days to choose and enroll in a new policy. During this special enrollment period, they may need to provide documentation to verify the qualifying life event. This documentation could include birth certificates, marriage licenses, divorce paperwork, and proof of residence, depending on the specific circumstances.
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Losing individual health coverage
- Loss of coverage through your employer or a family member's employer: If you lose your job-based health coverage due to leaving your job, you are eligible for an SEP in the individual market. This also applies if you lose health coverage through a parent or guardian because you are no longer a dependent. However, you will not qualify for an SEP if you voluntarily dropped your coverage during the plan year or lost coverage due to non-payment of premiums.
- Discontinuation of your individual plan: If your insurance carrier stops offering your individual policy, or your individual plan is discontinued (no longer exists), you may be eligible for an SEP.
- End of your individual health coverage year: If your individual health coverage year ends in the middle of the calendar year, and you do not renew it, you may qualify for an SEP.
- Loss of COBRA coverage: Exhausting your COBRA coverage triggers a special open enrollment window as it is considered a loss of other coverage. However, voluntarily ending COBRA early or losing COBRA coverage due to non-payment of premiums does not qualify you for an SEP.
It is important to note that you typically have 60 days following a qualifying life event to choose and enrol in a new policy. In some cases, you may be required to provide documentation to verify your qualifying life event.
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Losing Medicaid or CHIP coverage
Medicaid and CHIP are government-run health insurance programs that provide coverage for individuals and families who meet certain income and eligibility requirements. These programs offer health coverage to low-income individuals, families, children, pregnant women, the elderly, and people with disabilities. Losing coverage under these programs can be considered an "involuntary" loss of coverage, which is typically classified as a qualifying life event.
If you lose your Medicaid or CHIP coverage, you have several options to maintain your health insurance coverage:
- Apply for a Marketplace health plan: You can apply for a Marketplace plan, either through the federal Health Insurance Marketplace or your state's Marketplace, if your state runs its own. You can apply for a Marketplace plan as early as 60 days before your Medicaid or CHIP coverage ends to avoid a gap in coverage. Marketplace plans offer coverage for prescription drugs, doctor visits, urgent care, hospital visits, and more. You may also qualify for savings and discounts to lower your monthly premium and out-of-pocket costs.
- Re-apply for Medicaid or CHIP: Even if your state notifies you that you are no longer eligible for Medicaid or CHIP, you can re-apply through your state at any time to determine if you still qualify. Each state has its own eligibility criteria, and you may still meet the requirements.
- Job-based plan or Marketplace coverage: If your employer offers health insurance, you can consider enrolling in a job-based plan or opting for Marketplace coverage.
- Sign up for Medicare: If you meet the age requirements (65 or older) or have certain disabilities, you may be eligible to enrol in Medicare.
It is important to note that you may be required to provide documentation to verify your qualifying life event when enrolling in a new plan. Additionally, be cautious of scams and never share your personal information or make payments to anyone claiming to provide assistance with maintaining your health coverage.
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Frequently asked questions
Qualifying life events are circumstances that may impact your current health insurance coverage and make it necessary to enroll in a new plan.
Loss of coverage through your employer or a family member's company is a qualifying life event. Losing your insurance carrier or having your group health plan terminated also counts as a qualifying life event.
Voluntarily dropping your dependent coverage or losing your coverage because of non-payment of premiums or rescission does not count as a qualifying life event.
