Glossary of Human Resources Management and Employee Benefit Terms
A qualifying life event, as far as health insurance goes, is a change in situation (such as getting married or divorced, a change in residence, or a job loss) which makes a person eligible to enroll in health insurance outside of the yearly Open Enrollment Period.
A Qualifying Event for health insurance purposes is a major event that affects a person’s health insurance needs, and qualifies that person to make changes or buy a health plan immediately, even if it’s outside of open enrollment dates.
Generally, Special Enrollment lasts 60 days before or after the qualifying event takes place and allows an individual to immediately make plan changes or sign up for a new coverage.
An event that takes place which makes someone eligible for a health insurance Special Enrollment Period, rather than waiting for an Open Enrollment Period, is called a Qualifying Life Event.
There are four categories of qualifying life events:
Loss of health insurance
Changes in household
Changes in residence
Other qualifying changes
Turning 26 years old and losing coverage through a parent’s insurance plan
Losing job-based coverage, COBRA, or a student plan
Losing eligibility for Medicare, Medicaid, or the Children’s Health Insurance Program (CHIP)
Losing health insurance for any reason other than not paying the premiums
Getting married, separated, or divorced
Having a baby, adopting a child, or receiving a foster child
The death of someone on your health insurance policy
Moving to a different county or zip code
For students, moving to or from school
For seasonal workers, moving to or from a work location
Moving in or out of a shelter or transitional housing
Moving to the U.S. from a U.S. territory or foreign country
Changes in income that affect your eligibility for Medicaid coverage
After already having an ACA plan, becoming eligible for tax credits that lower premiums
Becoming a member of a federally recognized tribe
For new U.S. citizens, becoming eligible for Marketplace coverage
For AmeriCorps VISTA members, beginning or ending service
Being released from incarceration
In addition to the above-mentioned qualifying life events, there are times when an Exceptional Circumstance (also called Special Circumstance) takes place that may qualify a person for a Special Enrollment Period.
Having been kept from enrolling during Open Enrollment due to a serious medical condition or a natural disaster
If someone working in an official capacity prevented enrollment, made a mistake in enrollment, gave wrong information, etc.
If a technical error occurred or if wrong policy data was displayed on the Exchange
Applying for Medicaid or CHIP during open enrollment but being deemed ineligible after open enrollment ended
Gaining a new dependent or becoming dependent on someone else due to a court order
Surviving domestic abuse or spousal abandonment and enrolling in a new, personal health policy
Filing and winning an appeal after an incorrect eligibility determination
No, getting pregnant is not a qualifying life event for a special enrollment period in the marketplace. However, giving birth, adopting a child, or having a foster child placed in your home are qualifying life events.
No, getting a new job is not considered a qualifying event for special enrollment. However, gaining new employment may trigger a special enrollment period for the group coverage at the new job, should the employer offer it. Picking up employer-based coverage will trigger a disenrollment period for other coverage.
A special enrollment period generally lasts 60 days before or after the qualifying event and allows an individual to make plan changes or sign up for a new health insurance plan immediately.
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