An HR Glossary for HR Terms
Glossary of Human Resources Management and Employee Benefit Terms
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.
Marriage, divorce, and parenthood are all common examples of major 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 gives you 30 days (sometimes 60 days) to make plan changes or sign up for new coverage.
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4 Types of Qualifying Life Events
Loss of Health Insurance
The loss of health insurance coverage is a QLE. 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 QLE, 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 QLE. 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 U.S. from a U.S. territory or foreign country
Changes to Your Eligibility
Aside from the examples shared above, there are additional circumstances that are considered to be 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 U.S. 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.
Examples of events that qualify for special enrollment include :
- Having been kept from enrolling during Open Enrollment due to a serious medical condition or a natural disaster (such as a pandemic or hurricane)
- 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 or substantial contract violation
How Long Do You Have for a Qualifying Event?
A special enrollment period generally lasts 30-60 days before or after the qualifying event, during which an individual is allowed to make plan changes or sign up for a new health insurance plan immediately.
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 has come 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 event 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
- U.S. Citizenship: Naturalization certificate
Is Getting Pregnant a Qualifying Life Event?
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.
Is Getting a New Job a Qualifying Event?
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-sponsored coverage will trigger a disenrollment period for other coverage.
Is Changing Jobs a Qualifying Life Event?
No, changing jobs within an organization is not a qualifying life event. Your employer-based coverage will remain the same until you have the opportunity to make changes during the open enrollment period.
Is It a Qualifying Life Event If Your Spouse Gets a New Job?
No, a spouse getting a new job may not be considered a qualifying life event if the change did not initiate 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 does not 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’s insurance coverage, then your spouse quitting or leaving the job for whatever reason is considered a qualifying life event since your coverage will then be lost.
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