Understanding Life Events: Insurance Qualification Criteria

A qualifying life event is a life-changing situation that can impact your health insurance. These events allow you to change your health plan outside of the regular annual open enrollment period. Examples of qualifying life events include having a baby, losing health coverage, getting married, and moving to a different zip code or county. These events can trigger a Special Enrollment Period (SEP), during which you can apply for new health insurance coverage or make changes to your existing plan. It's important to note that the specific qualifying life events and the documentation required to confirm them may vary depending on your location and insurance provider.

Loss of health coverage

Losing health coverage is a qualifying life event that can make you eligible for a Special Enrollment Period (SEP). This allows you to enroll in a new health insurance plan outside of the yearly Open Enrollment Period, which usually lasts from November 1 to January 15. Losing health coverage can take several forms, including:

• Losing existing health coverage, such as job-based, individual, or student plans.
• Losing eligibility for Medicare, Medicaid, or the Children's Health Insurance Program (CHIP).
• Turning 26 and losing coverage through a parent's plan.

If you lose your health coverage, you may qualify for an SEP in the individual market. This is true even if you have the option to continue your employer-sponsored plan with COBRA. Losing coverage due to rescission, voluntary cancellation, or non-payment of premiums does not count as a qualifying life event.

To enroll in a new plan during an SEP, you may need to provide documentation verifying the loss of your previous coverage. This could include notices from your previous insurance company or employer. It is important to note that the timeframe for selecting a new plan during an SEP is typically limited to 60 days before or after the qualifying life event.

Changes in household

Getting Married

Marriage is a common life event that can affect your health insurance needs. When you get married, you may want to add your spouse to your existing health insurance plan or combine your coverage. This qualifies as a life event, and you can make these changes outside of the annual Open Enrollment Period.

Getting Divorced

Similarly, if you get divorced, you may need to remove your former spouse from your health insurance plan or make changes to your coverage. Divorce is considered a qualifying life event, allowing you to make these adjustments outside of the regular enrollment period.

Having a Baby or Adopting a Child

Expanding your family through the birth of a child or adoption is another significant life event that can impact your insurance needs. You will likely want to add your new child to your health insurance plan, and this qualifies as a life event, enabling you to modify your plan accordingly.

Death of a Family Member

The death of a family member, especially the primary policyholder, can be a life-changing event that affects your insurance situation. You may need to adjust your coverage and make changes to your plan. This type of event qualifies for a Special Enrollment Period, allowing you to make the necessary modifications.

It's important to note that these are just a few examples of changes in household circumstances that can trigger a Special Enrollment Period. Each insurance provider may have specific guidelines, so it's always a good idea to contact your insurer to understand your options and any documentation requirements for making changes to your health insurance plan.

Changes in residence

A change in residence is considered a qualifying life event if it involves relocating to a different zip code, county, or state that changes your health plan area. This includes situations such as:

• Moving to a different county or zip code.
• Students moving to or from their school location.
• Seasonal workers moving to or from their work location.
• Moving in or out of a shelter or transitional housing.
• Moving to the United States from a U.S. territory or foreign country.

To enrol in a new health insurance plan or change your existing plan during an SEP, you may be required to provide documentation of your change in residence. This could include proof of residency from your new and old addresses, such as new rental agreements, deeds, or mortgages.

Changes in income

Income changes that may qualify you for a Special Enrollment Period (SEP) include:

• Changes in income that affect your eligibility for Medicaid coverage.
• An increase in income that moves you out of the Medicaid coverage gap.
• Changes in income that affect the coverage you qualify for.
• An increase in income that affects your subsidy eligibility (may not apply off-exchange in states that run their own exchanges).

Other Qualifying Life Events

Aside from changes in income, other common examples of major life events that are considered QLEs include:

• Loss of health insurance coverage.
• Changes in household, such as getting married, divorced, or having a baby.
• Changes in residence, such as moving to a different zip code or county.

Loss of eligibility for Medicare, Medicaid or CHIP

Losing eligibility for Medicare, Medicaid, or the Children's Health Insurance Program (CHIP) is a qualifying life event that triggers a special enrollment period (SEP) for health insurance. This means that if you lose eligibility for these programs, you can enroll in a new health insurance plan outside of the yearly Open Enrollment Period.

In the United States, the Open Enrollment Period for health insurance typically runs from November 1 to January 15, during which individuals and families can purchase a health plan through the Health Insurance Marketplace. However, a qualifying life event such as losing eligibility for Medicare, Medicaid, or CHIP allows for a Special Enrollment Period, enabling individuals to apply for essential health insurance coverage within 60 days before or after the qualifying life event.

It is important to note that the coverage options and specific dates may vary by state. For example, the Special Enrollment Period following the loss of Medicaid or CHIP coverage has been extended in some states through November 30, 2024.

If you lose eligibility for Medicare, Medicaid, or CHIP, it is recommended to contact your insurer or the Marketplace to understand your coverage options and any necessary documentation, such as proof of loss of eligibility.

Frequently asked questions