Qualifying Life Event – Types, Eligibility & Working

A qualifying life event is one that has life-changing consequences, but most importantly, it alters the benefits of your health insurance plan. On the occurrence of such events, it becomes necessary to enrol in or make changes to your health plan immediately, and you cannot wait for the open enrollment period to do so. Therefore, special enrollment periods are created to facilitate such changes and enrollments.

What’s a Qualifying Life Event?

An open enrollment period is typically a window of three months, between November and January, when individuals can enrol for and make changes to their health insurance plan. This restricted period is provided for under the Affordable Care Act to prevent people from misusing the guarantee of health insurance by enrolling only when they are in need of it. However, one may enrol for or make changes to their health insurance if they experience a qualifying life event. On the occurrence of such an event, a special enrollment period comes into effect and allows you to sign up for health insurance immediately. Qualifying life events are life-changing happenings like marriage, change in employment status, divorce, having a baby, etc. Depending upon the health plan, qualifying life event benefits have to be availed within a deadline, i.e., the special enrollment period, and failing to meet the deadline will mean that you have to wait for the next open enrollment period to make changes to your health plan.

What Are the Types of Qualifying Life Events?

A qualifying life event includes those life-changing situations that will allow you to make changes to your health plan. Here are the types of qualifying life events, accompanied by some qualifying life event examples:

1. Loss of Health Coverage

These events include losing coverage under your parent’s insurance plan after turning 26, losing eligibility for Medicaid, Children’s Health Insurance Program (CHIP) or Medicare, losing existing health coverage under a student plan, COBRA, or a job-based plan.

2. Change in Household

These events include getting married, getting divorced, losing health coverage because of legal separation, adopting a child or placing one for foster care, having a baby, or the death of a family member covered under your individual health plan.

3. Change in Residence

These events include a move to a different county or ZIP code, moving to or from transitional housing like a shelter, moving two or from a place of living and work (for seasonal workers), or a student moving to or from the place where they attend school.

4. Other Qualifying Events

Other qualifying events include obtaining United States citizenship and becoming eligible for Marketplace coverage, leaving incarceration, changes in income that affect qualification for coverage under Medicaid or CHIP, starting or ending service by AmeriCorps VISTA members, or becoming a member of a federally recognized tribe or obtaining the status of an Alaskan Native Claims Settlement Act Corporation holder.

What Are Non-Qualifying Life Events?

Non-qualifying life events are those which may have a life-changing impact on you but do not bear any significant impact on your health insurance. These circumstances don’t necessarily alter the benefits of your health plan. Non-qualifying life events include temporary changes in a residence like vacations, voluntary dropping of one’s insurance coverage, or cancellation of insurance due to non-payment of premium. Some qualifying life events that have no bearing on your health plan will also be non-qualifying life events.

How Does a Qualifying Life Event Work?

If you have experienced a qualifying life event and wish to make a change to your health plan, you are required to do so within a specified period. Most health insurance providers provide a period of 60 days, known as the special enrollment period. If you fail to make the necessary changes within this period, you will have to wait till the open enrollment period to make them.

What Is the Eligibility for Qualifying Life Events?

As soon as a qualifying life event occurs in your life, contact your health insurance provider to determine your eligibility to make changes within the special enrollment period. Since every event varies, documentation will be required to prove that you have experienced a qualifying life event and to show how the event has impacted your health plan.

Documents Needed for a Qualifying Life Event

The documents that you will need for a qualifying life event will depend upon the event and circumstances.

• Change in Legal Marital Status

For a marriage qualifying life event, a marriage certificate will be required in the event of a marriage, a divorce decree for a divorce, an annulment ruling by a Court for an annulment, a Court order for legal separation in the event of legal separation, and a death certificate for the death of a spouse.

• Change in Number of Dependents

In the event of a dependent’s death, a death certificate will be necessary. For a qualifying life event for parents, a birth certificate is required on the birth of a child, a Court order for adoption in the event of adoption, a Court order for placement for adoption while giving up a child for adoption, and when the child turns 26 years old and is no longer eligible under his parent’s health plan, proof of prior health coverage under the parent’s plan is to be submitted by the child.

• Change in Employment Status of Spouse or Employee

In the event of a loss of employment, termination documents on the company letterhead, a COBRA letter, and an unemployment application are required. For the beginning of new employment, employer documentation on the company’s letterhead, along with the date of commencing employment. In the event of a change in the worksite, employer documentation on the company’s letterhead is to be submitted, and it must reflect the change along with the impact it will have on eligibility under the existing health plan. In the event of a leave of absence, employer documentation on the company’s letterhead is to be submitted, reflecting that the employee has started or returned from leave.

• Gain/Loss of Eligibility Under Some Other Group Coverage

In the event of obtaining or losing coverage under a group health plan, documentation for the carrier or plan regarding the change in eligibility has to be submitted, containing the effective date as well.

• Change in Place of Residence

In the event of a permanent change in place of residence, or that of a spouse, employee, or dependent that affects eligibility, proof of a change in residence in the past 60 days, in the form of mortgage/rental documents or utility bills, along with proof of existing health insurance 60 days prior to the move has to be submitted.

How to Submit Your Documents

Once you have identified and accumulated the necessary documents, you are required to send them to your health insurance provider. This can be done online or offline, depending upon the company’s requirements. Some companies require you to submit the documents in person so that they may see the original or certified copies and make necessary verifications.

What Is a Special Enrollment Period and How to Apply

A special enrollment period is a period after the occurrence of a qualifying life event during which you can alter your health plan. These periods are typically 30-60 days long, and during this period, you must contact your healthcare provider, determine your eligibility and apply for the special enrollment period.

To apply, you have to go through healthcare.gov or your State’s exchange, and the manner of application depends upon whether you have had a qualifying life event or some other special circumstance. To determine which one, you can take a screening test on healthcare.gov where you can answer a few questions based on the event that you have experienced. For qualifying life events, you can apply online. For special circumstances, you are required to contact the Marketplace directly in order to determine eligibility for a special enrollment period.

If your special enrollment period application has been denied, you can file an appeal if you think that the decision is wrong. The appeal form can be downloaded on healthcare.gov and can be mailed to the Marketplace with a copy of your eligibility determination notice.

Cases That May Qualify for a Special Enrollment Period

If you have not experienced a qualifying life event but some other special circumstance, you can qualify for a special enrollment period. These special circumstances are complex cases where eligibility is determined on a case-to-case basis, depending on the specific circumstance. These may include:

• Experiencing some exceptional circumstance

An exceptional circumstance includes serious medical conditions or natural disasters as a result of which you were unable to enrol during the open enrollment period.

• Experiencing a policy information display or enrollment error

If an official, like your insurance agent or the insurance company, has prevented you from enrolling for a policy or the correct policy or from obtaining the premium tax credit or cost-sharing reduction you were eligible for, you become eligible. This also happens if there is a technical error or wrong policy data has been displayed.

• Being determined ineligible for Medicaid or CHIP

If you have been deemed ineligible for an application after open enrollment has ended, if you made the application during the open enrollment, you are eligible.

• Gaining or becoming a dependant due to a court order

If you gain a new dependent or become one due to a court order, you can access special enrollment.

• Experiencing spousal abandonment, domestic violence, or abuse

A special enrollment period is provided by the federal government for the survivors of spousal abandonment or domestic abuse so that they may enrol in their own health plan. Their dependents will also be eligible.

• Getting a favorable appeal decision

If you win your appeal against an incorrect eligibility determination, you can enrol for the special enrollment period.

How Long Does Special Enrollment Period Last?

A special enrollment period is usually 30-60 days long, and the exact time period can be determined from the federal exchange or your State’s exchange. Within the passage of this period after the occurrence of a qualifying life event, you should enrol or make changes in your health insurance policy. If you anticipate that you are going to lose your health insurance coverage within the coming 60 days, maybe due to your decision to leave your job or get married, you can seek access to the Special enrollment period earlier as well.

What If You Do Not Have a Qualifying Life Event?

If you fail to obtain health coverage during the special enrollment period, you can opt for short-term flexible insurance plans to meet the immediate essential need. However, do not rely on these plans as their coverage is often inadequate. Make sure that you enrol during the next open enrollment period. Some short-term alternatives are:

• Medicaid – You can apply for Medicaid at any time of the year if you qualify.

• Specialized Health Insurance Plans – Certain plans are designed to provide coverage during life-changing events.

• Qualified Small Health Reimbursement Arrangement (QSEHRA) or Individual Coverage Health Reimbursement Arrangement (ICHRA) – Some companies offer these agreements to reimburse qualified medical expenditure.

Health insurance is an indispensable need, and you must make timely enrollments and changes to your health plan as necessary. If you have experienced a qualifying life event or special circumstance, contact your healthcare provider immediately and apply for the special enrollment period.

Also Read:

Reasons to Have Travel Insurance
Importance & Types of Life Insurance
Reasons to Get a Maternity Insurance