What Is a Qualifying Life Event?
By: Caitlyn Bronson, Zane Benefits, July 2017
When the Affordable Care Act went into effect, it guaranteed that everyone who applied for individual health insurance would be approved for and enrolled in coverage. However, to prevent people from signing up for insurance only when they get sick, the ACA restricted enrollment to specific open enrollment periods—typically a period of three months from November to January.
If you want to purchase an individual health insurance policy, either on your own or because your employer offers a Qualified Small Health Reimbursement Arrangement (QSEHRA), you usually must wait until the next open enrollment period.
However, if you experience a qualifying life event, a special enrollment period will go into effect, and you can sign up for health insurance immediately.
These special enrollment periods apply to qualified health policies purchased through both the state and federal health insurance exchanges and outside the exchanges through a broker or health insurance website.
In this post, we’ll go over the qualifying life events that trigger a special enrollment period. We’ll also discuss what you need to do once the special enrollment period starts.
Qualifying life events that open a special enrollment period
A qualifying life event is an event in your life that makes you eligible for a special enrollment period. The special enrollment period generally lasts 60 days before or after the qualifying life event.
There are four basic types of qualifying events: loss of health coverage, changes in household, changes in residence, and other.
Here’s a full list of all life events that qualify for a special enrollment period, organized by those four categories. We’ll examine each of the events in the first two categories in more detail below. The events listed under the second two categories are self-explanatory.
Loss of health insurance
– Losing job-based coverage
– Losing COBRA coverage
– Losing individual health coverage for a plan or policy you bought yourself
– Losing eligibility for Medicaid or Children’s Health Insurance Program (CHIP)
– Losing eligibility for Medicare
– Losing coverage through a family member
Changes in household
– Getting married
– Having a baby, adopting a child, or placing a child for foster care
– Getting divorced or legally separated and losing health insurance
– Death of someone on your individual health insurance policy
Changes in residence
– Moving to a new home in a new zip code or county
– Moving to the United States from a foreign country or U.S. territory
– Moving to or from the place you attend school, if you’re a student
– Moving to or from the place you both live and work, if you’re a seasonal worker
– Moving to or from a shelter or other transitional housing
Other qualifying changes
– Changes that make you no longer eligible for Medicaid or CHIP
– Gaining membership in a federally recognized tribe or status as an Alaska Native
– Claims Settlement Act (ANCSA) Corporation shareholder
– Becoming newly eligible for Marketplace coverage because you became a U.S. citizen
– Leaving incarceration
– AmeriCorps VISTA members starting or ending their service
Losing job-based coverage
If you lose health coverage through your company or a family member’s company, you might qualify for a special enrollment period.
Common reasons for losing job-based coverage are:
– Your company drops coverage.
– You quit or were fired from a job where you had coverage.
– You experienced a reduction in work hours that caused you to lose your job-based coverage.
– Your job-based coverage doesn’t qualify as minimum essential coverage (MEC) and you’re eligible for a premium tax credit.
You won’t qualify for a special enrollment period if you lost your job-based coverage because you voluntarily dropped coverage during the plan year or you lost your coverage because you didn’t pay your premium.
Losing COBRA coverage
If you’re losing COBRA continuation coverage because the coverage ran out or your former company stops contributing, causing you to pay the full cost, you qualify for a special enrollment period.
However, you won’t qualify if you decide to end COBRA early and are paying the full cost yourself or if you lost your COBRA coverage because you didn’t pay your premiums.
Remember, you don’t need a special enrollment period if you voluntarily end COBRA during open enrollment. At that time, you can drop your COBRA policy and enroll in an exchange policy.
Losing individual health coverage for a plan or policy you bought yourself
If you lose individual health coverage, you may qualify for a special enrollment period in the following circumstances:
– Your insurance carrier stops offering your individual policy
– You lose eligibility for a student health policy
– You lose eligibility for a policy because you no longer live in the policy’s service area
– Your or group health policy’s coverage year ends in the middle of the calendar year and you don’t renew it
If you voluntarily drop coverage or lose your coverage because you didn’t pay your premiums or provide required documentation to the exchange when prompted, you won’t qualify for a special enrollment period.
Losing eligibility for Medicaid or CHIP
If you lose eligibility for Medicaid or CHIP, you might qualify for a special enrollment period. This could be due to a change in income, or because you become ineligible for pregnancy-related or medically needy Medicaid.
Additionally, if your child ages off CHIP, you may qualify.
Losing eligibility for Medicare
You may access a special enrollment period if you lose eligibility for premium-free Medicare Part A.
You won’t qualify, however, if you lose Medicare Parts B, C, or D only, or if you lose Medicare Part A because you didn’t pay your premium.
Losing coverage through a family member
Losing coverage through a family member, such as a parent or spouse, also qualifies you for a special enrollment period.
This could happen if:
– You turn 26.
– You are no longer a dependent of your parent or guardian.
– Your family member’s employer cuts health coverage for dependents.
– Your family member dies.
– You divorce or legally separate from the spouse through whom you have health insurance.
If you voluntarily drop coverage you have as a dependent, you won’t qualify for a special enrollment period. Similarly, you won’t qualify for coverage if neither you nor your family member pays the premium.
Getting married
If you’ve gotten married in the past 60 days, you can apply for coverage through a special enrollment period. Pick a policy by the last day of the month for your coverage to begin the first day of the next month.
Having a baby, adopting a child, or placing a child for foster care
Apply for coverage within 60 days of having a baby, adopting a child, or placing a child for foster care. Your coverage will be retroactive to the day of the event.
Getting divorced or legally separated and losing health insurance
You only qualify for a special enrollment period if divorcing or legally separating from your spouse caused you to lose health insurance.
Death of someone on your individual health insurance policy
If someone on your policy dies and, as a result, you’re no longer eligible for your policy, you’ll be eligible for a special enrollment period.
Other cases that may qualify you for a special enrollment period
There are other special circumstances that may qualify you for a special enrollment period. Though these circumstances aren’t considered qualifying life events, they could open a special enrollment window for you.
We’ll list these complicated cases and explain them in more detail below.
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– Experiencing an “exceptional circumstance”
– Experiencing an enrollment or policy information display error
– Previously having lived in a state that hasn’t expanded Medicaid and you became newly eligible for help paying for an insurance plan because of an increase in household income or move
– Being determined ineligible for Medicaid or CHIP
– Gaining or becoming a dependent due to a child-support or other court order
– Experiencing domestic abuse or violence or spousal abandonment
– Getting an appeal decision that’s in your favor
Experiencing an “exceptional circumstance”
If you faced a serious medical condition or natural disaster that kept you from enrolling during open enrollment, you’re entitled to a special enrollment period. Healthcare.gov lists as examples: unexpected hospitalization; temporary cognitive disability; or a natural disaster like an earthquake, massive flooding or a hurricane.
Experiencing an enrollment or policy information display error
You’re entitled to a special enrollment period if someone working in an official capacity kept you from enrolling in a policy, enrolling in the right policy, or getting the premium tax credit or cost-sharing reduction you were eligible for.
Potential individuals or groups in error could be an insurance company, an exchange navigator, or an insurance agent or broker. Misinformation, misrepresentation, misconduct, or inaction all qualify as enrollment errors.
You’re also entitled to a special enrollment period if you experienced a technical error when you applied on your public exchange. If you saw an error message when completing your application that prevented you from enrolling in a policy or your carrier from receiving your enrollment information, you can access a special enrollment period.
Similarly, if the wrong policy data was displayed on the exchange—such as benefit or cost-sharing information—when you selected the policy, you’ll qualify for a special enrollment period.
Previously having lived in a state that hasn’t expanded Medicaid and you became newly eligible for help paying for an insurance plan because of an increase in household income or move
If you previously lived in a state that hasn’t expanded Medicaid and you weren’t eligible because your income was too low, you can qualify for a special enrollment period if you moved or had an increase in household income that makes you newly eligible for Medicaid or advance payments of your premium tax credit within the last 60 days.
Being determined ineligible for Medicaid or CHIP
If you applied for Medicaid or CHIP during the open enrollment period and were deemed ineligible after open enrollment ended, you may qualify for a special enrollment period. This is true whether you applied through your local exchange or your state Medicaid or CHIP agency directly.
Gaining or becoming a dependent due to a child-support or other court order
You can access a special enrollment period if you either gained a new dependent or became a dependent of someone else due to a court order. Your coverage will start the effective date of the court order, even if you enroll in the policy up to 60 days afterward. In other words, your coverage would be retroactive to the date of the court order.
Experiencing domestic abuse or violence or spousal abandonment
The federal government grants special enrollment periods to survivors of domestic abuse and spousal abandonment who want to enroll in their own health policy. Dependents may also be eligible.
If you want to claim this special enrollment period, you need to contact the Marketplace Call Center. If you’re married to your abuser or abandoner, you can fill out your application as unmarried without being penalized for misstating your marital status. You’ll also be able to collect a premium tax credit if you qualify based on your income.
Getting an appeal decision that’s in your favor
You can enroll in or change policies if you file and win an appeal with your exchange after receiving an incorrect eligibility determination for a special enrollment period or an incorrect coverage effective date.
Applying for a special enrollment period
If you’ve experienced one of the events above and want to apply for a special enrollment period, you’ll need to do so through Healthcare.gov or your state exchange.
How you apply depends on whether you’ve had a qualifying life event or another special circumstance.
If you have a qualifying life event, you can apply online. If you’re not sure whether you qualify, Healthcare.gov can screen you by asking you a few questions on any events you’ve experienced that would open a special enrollment period.
Once you’ve determined you’re eligible, you can start a 2017 application for insurance coverage or log in to your existing account.
If you have a special circumstance rather than a qualifying life event, contact the Marketplace directly. You can reach the call center at 1-800-318-2596. The representative will ask about your situation and help you determine whether it qualifies you for a special enrollment period.
Filing an appeal
If your request for a special enrollment period is denied and you feel the decision is wrong, you can file an appeal.
To do so, select your state’s appeal form through Healthcare.gov, download it, and fill it out. If possible, attach a copy of your eligibility determination notice and any other official notice you received.
Mail the appeal to:
Health Insurance Marketplace
Attn: Appeals
465 Industrial Blvd.
London, KY 40750-0061
Be sure to include the last four digits of the zip code as this helps your appeal arrive faster.
Verifying your qualifying life event and enrolling in coverage
In most circumstances, you’ll have 60 days following your qualifying life event or special circumstance to choose and enroll in a policy. As part of this process, you may need to verify your qualifying life event or special circumstance through documentation.
You’ll be told whether you need to submit documentation before you submit your application for coverage. In some cases, you may not need to provide anything at all.
If you are asked, however, Healthcare.gov advises you to pick a policy first and submit documentation afterward. Once you pick a policy, you’ll 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 get in the mail.
Once you’re ready to submit documents, upload them to Healthcare.gov or send photocopies of the original documents to:
Health Insurance Marketplace
Attn: Supporting Documentation
465 Industrial Blvd.
London, KY 40750-0001
In general, the documentation required depends on your qualifying life event. We’ll go over two common reasons people qualify for a special enrollment period, the documentation they should submit, the timeline for submitting that coverage and picking a policy, and the time coverage starts once the first premium payment is made.
For all other documentation concerns, as well as a full list of acceptable documents to verify special enrollment periods, see Healthcare.gov.
Losing health coverage
Whether you already lost your health coverage or you will in the future, you’ll have 60 days following the end of your coverage to choose a policy.
You’ll need to submit documents verifying that your coverage has ended or will end, along with the date it ends. Acceptable documents may be notices from your previous insurance company or your employer. You should submit these within 30 days of choosing a policy.
If your coverage has ended, your new coverage will begin the first day of the month after you choose the new policy. If your coverage will end in the future, your new coverage will begin the first day of the month after your old coverage ends and you choose a new policy.
Remember, your coverage won’t be go into effect unless your eligibility is confirmed and you make your first premium payment.
Moving to a new address and previously had insurance
If you’re moving to a new address, you’ll need to choose a policy within 60 days from the date you moved.
You’ll also need to provide documents confirming both your move and proof of former coverage. To verify your new address, you can submit government correspondence, utility bills, rental or mortgage documents, or homeowner’s insurance. The documents must include your new address and the date of your move.
To verify that health coverage, you must submit documents showing that you were covered at least 1 day during the 60 days before your move. These documents may be correspondence from your insurance company, employer, or health coverage provider. If you’re moving from a foreign country or U.S. territory, you don’t need to provide this documentation.
You must submit all documents within 30 days of choosing a new policy.
If you choose a policy between the first and fifteenth of the month, your coverage will start on the first day of the next month.
If you choose a policy between the sixteenth and the last day of the month, your coverage will start on the first day of the second month following policy selection. For example, if you choose a policy on July 20, your policy will go into effect August 1.
What to do if you don’t have a qualifying life event or special circumstance
If you want to sign up for health insurance outside of open enrollment and haven’t experienced an event on this list, then you’ll have to wait until the next open enrollment period starts.
There is some relief for people whose companies offer a QSEHRA, though. If you’re looking for a health insurance policy because your company is offering a QSEHRA, you won’t be able to purchase one until open enrollment—but you will be able to submit your qualified medical expenses for reimbursement. The only thing you need to do is include these reimbursements as part of your gross income. Once you get a policy, you’ll be able to receive these reimbursements tax-free.
