Qualifying Life Event

What is a qualifying life event for insurance?

A qualifying event for insurance is a change in life situation that makes a person eligible to enroll in health insurance outside of the annual Open Enrollment Period.

With the passing of the Patient Protection and Affordable Care Act (ACA) in 2010, the federal government started to provide greater consumer protections to make health insurance more affordable and accessible nationwide.

Marriage, divorce, and parenthood are all common examples of major qualifying life events that affect a person’s health insurance needs. Under these circumstances, an individual qualifies to immediately buy or make changes to a health plan.

Depending on your plan, a qualifying life event for health insurance gives you 30 days (sometimes 60 days) to make plan changes or sign up for new coverage.

Four types of qualifying life events

Let’s explore the list of qualifying life events that can impact your health insurance and other employee benefits.

Loss of health insurance

The loss of health insurance coverage is a qualifying life event. This may happen when you are:

• 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.

Changes in household

There are a few household changes that will trigger a qualifying life event, such as:

• Getting married, separated, or divorced
• Having a baby, adopting a child, or receiving a foster child
• Experiencing the death of someone on your health insurance policy.

Changes in residence

When you change residence, you may qualify for a qualifying life event. For example:

• 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 US from a US territory or foreign country.

Changes to your eligibility

Aside from the examples shared above, there are additional circumstances that are considered qualifying life events, including:

• 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 US citizens, becoming eligible for Marketplace coverage
• For AmeriCorps VISTA members, beginning or ending service
• Being discharged from the military
• Being released from incarceration.

Special enrollment period examples

There are times when an Exceptional Circumstance (also called Special Circumstance) takes place that may qualify a person for a Special Enrollment Period (SEP).

Examples of qualifying life events for special enrollment include:

Unexpected situations

If you were kept from enrolling during open enrollment due to unforeseen circumstances, such as:

• A serious medical condition or unexpected hospitalization
• A natural disaster, such as an earthquake or hurricane

Technical errors and misinformation

Enrollment or plan information display errors also count as qualifying life events for a SEP, including:

• If someone working in an official capacity prevented enrollment, made a mistake in enrollment, or gave wrong information
• If a technical error occurred or if wrong policy data was displayed on the Exchange
• Not qualifying for Medicaid/CHIP Coverage

If you applied for Medicaid or CHIP during open enrollment but were deemed ineligible after open enrollment ended, you may qualify for an SEP.

Court orders or spousal abandonment

Certain court orders and spousal abandonment circumstances may also count as a qualifying life event for an SEP, particularly if you are:

• 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

Successful appeal decision

Filing and winning an appeal after an incorrect eligibility determination or substantial contract violation can also grant you an SEP.

How long do you have for a qualifying life event?

A special enrollment period generally lasts 30–60 days before or after the qualifying life event, during which an individual is allowed to make plan changes or sign up for a new health insurance plan immediately. During a qualifying life event, the HR team should support the employee where applicable.

There are three dates you must check with your plan before assuming you are covered:

• The date your eligibility is confirmed
• The date your coverage starts
• The date of your first premium payment

What qualifying life event documentation do you need to provide?

When the time comes to buy a new plan or make changes to an existing plan, there is certain qualifying life event documentation that you may need to provide to become eligible. Documentation needs to be submitted within 30 or 60 days (depending on the plan), and each piece of documentation needs to be signed and dated. When documents are difficult to provide, an affidavit is usually sufficient.

Different qualifying life events require specific documentation:

• Aging out of a parent’s plan:  Proof of prior coverage within the last 60 days
• Becoming a Parent:  Birth certificate or adoption record
• Death:  Death certificate
• Getting Married:  Marriage certificate
• Getting a Divorce:  Filed court papers
• Government Enrollment Error:  Signed affidavit
• Job Loss:  Termination letter
• Military Discharge:  Certificate of Release
• Moving:  Proof of residency from new and old addresses
• US Citizenship:  Naturalization certificate

Is getting pregnant a qualifying life event?

No, getting pregnant isn't 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.

Is getting a new job a qualifying event?

Getting a new job is sometimes considered a qualifying life event for special enrollment, if it meets certain criteria or results in a loss of coverage. 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-sponsored coverage will trigger a disenrollment period for other coverage.

Is it a qualifying life event if your spouse gets a new job?

Your spouse’s employment status is only considered a qualifying life event if the change initiates a loss of insurance for you or your spouse.

Is a furlough a qualifying life event?

Yes, under some circumstances.  A furlough is considered a qualifying life event if it results in your loss of eligibility or your employer drops coverage. However, if your employer extends eligibility and coverage throughout the leave, then it doesn't qualify.

Is a spouse quitting a job a qualifying life event?

Yes, under some circumstances.  If your spouse’s employer was providing you and your spouse with insurance coverage, then your spouse quitting or leaving the job for whatever reason is considered a qualifying life event because it will result in a loss of coverage.