Every year, Americans are allowed a specific window of time to change or enroll in individual and family private health insurance coverage for the following year. This is known as the Open Enrollment Period (OEP), which typically lasts from November to mid-January.
But what if you need to enroll in health insurance outside of that timeframe? You have options! Let’s walk through how a qualifying life event could make you eligible for a Special Enrollment Period and what kind of life changes qualify.
What is a qualifying life event?
A qualifying life event (QLE) is a change in your current situation that makes you eligible to enroll in a health plan outside of the Open Enrollment Period. Also called a qualified status change, a QLE triggers a Special Enrollment Period (SEP). This ensures that people going through specific life changes, especially ones that result in loss of health coverage, can enroll in a new health plan.
How many days after a qualifying life event do you have to enroll in a health insurance plan?
In most situations, you have 60 days from the date of a qualifying life event to apply for health coverage. But this looks different from state to state. Depending on the situation, some states will allow you a 60-day window both before and after a qualifying life event to enroll in coverage.
A change in household size may make you eligible for an SEP
When the size of your household changes, your coverage must be adjusted to reflect that change. Your household includes you, your spouse and any dependents you may have, like children. There are a lot of ways your household size can change depending on what sort of life event you’re experiencing. Let’s take a look at what may qualify you for a special enrollment period.
Getting married counts as a qualifying life event
For those getting married, you’ll be allowed a 60-day window from the date of marriage to change your coverage, including adding a spouse to your employer-sponsored health plan.
Is divorce or legal separation a qualifying event for special enrollment?
In the event of a divorce, the spouse who does not hold the policy may be able to purchase their own individual plan through an SEP if they have a divorce decree or proof of legal separation. However, this can get complicated depending on legal proceedings and state rules.
Getting pregnant is not a qualifying life event
Though this varies by state, in most cases, getting pregnant is not considered a qualifying life event. But don’t worry – if your prenatal care is provided in-network, your current insurance should cover it. It’s important to call your insurance provider and ask questions before your first prenatal appointment to see what your insurance will and will not cover.
Does having or adopting a child qualify you for a special enrollment period?
Giving birth and adopting are both considered qualifying life events, as you are adding a new dependent to your health insurance and changing the size of your household. Typically, parents have 60 days from a baby’s delivery or a child’s adoption to enroll coverage for their little one.
A death in the family is a qualifying life event
If you share health coverage with a family member who passes away, it is a qualifying life event. Examples can include the loss of the primary holder of your family’s health insurance policy, the loss of a minor child and the loss of a family member whose income contributed to the insurance coverage.
Loss of health coverage may qualify you for an SEP
In most cases, an involuntary loss of health coverage, such as from divorce or the death of a family policy holder, makes you eligible for an SEP. But what about voluntary? And what’s considered “voluntary loss”?
You won’t qualify for a Special Enrollment Period if you voluntarily dropped your coverage. This includes losing your coverage because you didn’t pay your premiums or choosing to drop off a parent or guardian’s plan.
Is losing or getting a new job a qualifying life event?
Yes, if you lose your employer-sponsored health care, you're eligible for a Special Enrollment Period. There’s no distinction between leaving your place of employment willingly, like in the case of resignation, or unwillingly, like with a layoff or firing.
If you quit your job, are you still eligible for the special enrollment period?
Yes, leaving a job, no matter what the situation, counts as an involuntary loss of health insurance. This might be surprising if you left your job voluntarily but think of it this way – while you may be choosing to leave your job, you’re not technically choosing to lose your health coverage.
Losing your Medicaid coverage can make you eligible for special enrollment
You may be eligible for an SEP if you are denied or lose Medicaid coverage due to income changes, a child in your household ages out of the Children's Health Insurance Program (CHIP) or another qualifying circumstance occurs. To learn more, you can get in touch with your state’s Medicaid office.
Is a spouse quitting their job a qualifying life event?
Yes. If your spouse quits their job, it’s considered an involuntary loss of health coverage, no matter the situation. If they were the one whose employment provided health insurance, you would be able to seek a new plan during a Special Enrollment Period. If your spouse leaves their job and you want to fold them into your health coverage, this will also trigger an SEP.
Turning 26 and aging off a parent’s plan can make you eligible for an SEP
Turning 26 is a qualifying life event. This is when most dependents lose access to their parents’ health insurance coverage. Depending on where you live, you may have 60 days before your coverage ends and 60 days after finding a new plan during a Special Enrollment Period.
A change in residence is often considered a qualifying life event
Changing your residence to a new location, with the intention of living there permanently or indefinitely, is often considered a qualifying life event. Here are some examples that qualify as a QLE.
Moving to a new ZIP code or county can make you eligible
If you move out of your health plan’s coverage range, you may be eligible to enroll in a new plan during an SEP. According to HealthCare.gov, this may include moving to a new ZIP code or leaving a transitional housing situation, such as a shelter.
Is relocating for school considered a qualifying life event?
If you’re a student moving out of state for college, you may also be eligible to enroll in a new plan through an SEP, so make sure to consider your student health insurance options well in advance. To qualify, you must be a health plan policy holder, not a dependent on a parent’s plan.
Steps to take after experiencing a qualifying of life event
If you’ve experienced a qualifying life event, it’s time to check with your state’s marketplace website or work with a broker or health insurance company to confirm the window in which you’re eligible to enroll in a new plan. If you find that your situation applies, you can start shopping for a new health insurance plan.
Typically, most people begin to explore their coverage options within the state or federal health insurance marketplace or you can shop for a private individual or family plan directly with a health insurance company.
Once you find a plan to enroll in, you might have to provide documentation confirming your QLE – this can include a marriage certificate, birth certificate for a newborn, evidence of relocation, and more. Have these things on hand when you’re enrolling to make it easy as possible.
What are my options if I don’t qualify for a special enrollment period?
If you don’t qualify for a special enrollment period, don’t panic – there are other insurance options you can look into.
For instance, depending on your state, you may be able to enroll in a private short-term health insurance plan. However, it’s important to keep in mind that many of these plans are temporary and have a limit on how long you can keep coverage – some end after 6 months. And many short-term plans aren’t qualified health plans, meaning they aren’t compliant with Affordable Care Act (ACA) minimum standards.
Also, if you’re eligible, you may be able to enroll in Medicaid or the Children’s Health Insurance Program (CHIP) at any time. These federal and state programs often have strict eligibility requirements based on yearly income and household size. To see if you might qualify, you can head to your state’s Medicaid website for more information.
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