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Qualifying Life Events: What You Need to Know

by | Feb 19, 2024 | Health Insurance | 0 comments

The annual open enrollment period (on the ACA public health insurance market) typically runs from November 1st to January 15th and allows individuals to change, renew, or enroll in a health insurance plan. But what if you find yourself needing coverage after the deadline?

Qualifying life events are situations that can make you and your family eligible for a special enrollment period, giving you the ability to make changes to your health insurance outside of open enrollment. 

How does a qualifying life event work?

A qualifying life event can be expected or unexpected and includes things like moving, a change in household, or loss of health coverage. 

You usually have 60 days after experiencing a qualifying life event to shop or make changes to your health plan, so it’s best to notify your provider as soon as possible. This timeline can vary based on your state and the type of event. 

You may also need to provide documentation as proof that the qualifying life event has happened. This could be a birth certificate, a new mortgage or lease agreement, marriage/divorce papers, etc.

What is a qualifying life event?

There are four main categories of qualifying life events. Within these categories are several different types of situations and circumstances. 

The four categories are:

Loss of Health Coverage

Losing your current health plan is often a qualifying life event, especially when involuntary. This includes situations such as:

  • Losing a family member’s coverage. This applies when turning 26 and losing parental coverage, but would not apply if you’re under 26 and choosing to drop out of your  parents’ plan. It also covers the death of someone you share a health plan with, such as a spouse or parent, as well as divorce (if the divorce itself has caused a loss of coverage).
  • Losing job-based coverage. This includes voluntarily (resigning or retiring) as well as involuntarily (being laid off or fired) leaving your job. Another valid reason for losing job-based coverage is if the plan becomes unaffordable, which is when the employee’s cost for the premium exceeds 8.39% of their household income. It also applies if your spouse has quit or lost their job.
  • Losing individual coverage or  eligibility for Medicare, Medicaid, or Children’s Health Insurance Program (CHIP). 

Keep in mind that to qualify for special enrollment, you must be losing minimum essential coverage. Losing short-term health insurance would not be considered a qualifying life event. Voluntarily canceling or being unable to pay for your coverage are also not eligible situations.

Changes in Household

A change in household is another common category of qualifying life events. As mentioned before, this would cover the death of a family member enrolled in your plan, as well as getting a divorce that has directly caused you to lose coverage. Changes in household also include:

  • Marriage. You can qualify for special enrollment for a period of 60 days from your wedding date. However, at least one partner must have had minimum essential coverage in the 60 days prior to the wedding.
  • Birth or adoption. If you are gaining a dependent, your entire household can be eligible for special enrollment.

When using marriage as a qualifying life event, your insurance will become effective on the first of the next month after you apply. When adding a dependent, the insurance will be backdated to the date of the birth or adoption. For these reasons, it can be advantageous to use your qualifying life event to trigger special enrollment even during the open enrollment period, as insurance gained through open enrollment doesn’t take effect until January 1st at the earliest.

Changes in Residence

In order for a change of residence to be considered a qualifying life event, it needs to be a permanent move to an area where the health plans available are different from where you currently live. This could include moving to another state or even moving to a different part of the same state. 

It also doesn’t matter whether or not your current plan is available in the new area—as long as there are new options for health insurance that you didn’t have at your previous residence, you are eligible to make a change through special enrollment. However, in many cases you must already have some type of coverage before moving, so it is best to consult with an insurance professional to understand your unique situation.  

Other qualifying events for insurance

There are various other eligible circumstances that aren’t covered in the previous groups. This includes: 

  • Becoming a US citizen or lawfully present resident.
  • Leaving incarceration.
  • Moving out of the Medicaid coverage gap through increased income.
  • Having a health plan that renews at a time other than January 1st.
  • An error with enrollment that was not your fault.
  • Your plan substantially violates its contract.

While this covers most types of qualified life events, there are some special situations that are handled on a case-by-case basis, such as a natural disaster that occurs during the open enrollment period.

What happens if I miss the timeline?

If you have successfully applied for special enrollment, you generally have 60 days to choose your plan, which will become effective on the first of the next month. If you miss this deadline or do not qualify, you will have to wait until open enrollment begins again to get coverage on the exchange. However, there are alternative plans available outside of these traditional channels. 

If you’re looking for new health insurance or want to alter your existing plan, you should always try to use the window of time available in the open enrollment period. But, big life changes happen at all times of the year, and it’s important to understand qualifying life events in case you find yourself needing new insurance outside of open enrollment. 

It helps to have someone on your side when navigating the healthcare system. Book a call with me to get expert advice and support in developing an effective health insurance strategy. 

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