Qualifying life events are situations that trigger a special enrollment period for you to purchase health insurance outside of the annual enrollment period. The annual enrollment period opens every year from November 1 through December 15, allowing you to enroll in new plans or change your current health insurance. If you experience certain life events such as getting married, moving to a new area, or getting divorced, you could qualify for a special enrollment period.
Common Qualifying Life Events for Insurance
If you have one or more qualifying life events happen outside of the normal enrollment period, insurers may allow you to change your health plan to ensure that you’re protected. If you are eligible for a special enrollment period, you can apply within 30 to 60 days of the event, such as if you experience changes in your family, current coverage, or residency.
Changes In Your Household
Marriage or domestic partnership
Newlyweds are only eligible for a qualifying life event if one of the spouses has already had coverage for 60 days prior to their wedding.
The effective date for the new health insurance plan will be the first month after the plan is purchased. For example, if you and your spouse get married on March 3 and enroll in a health plan on March 15, your health insurance will officially begin on April 1.
Divorce or ending a domestic partnership
Your ex-spouse cannot remain as a family member under your health plan. After your divorce or annulment, you may change your policy to ensure your ex-spouse can enroll in an individual policy of their own.
If you have other family members listed on your family health plan, you may ask to remove just your ex-spouse from the plan. Bear in mind that if you fail to let the insurer know about your separation, this may be considered insurance fraud. However, if you decide to keep your ex-spouse on your plan, you must formally notify your insurer. Contact your specific insurance company to learn the exact steps you need to take.
Birth, adoption, or foster care of a child
Parents do not have to be insured at the time of birth or adoption. You may enroll in a health plan at the time of birth or adoption at any metal level — Bronze, Silver, Gold, or Platinum. If you’re already insured, a child could be added to your existing plan.
Court order for child support
One component of child support is health insurance, which is considered a Medical Child Support Order issued by the court. If both of the parents have health insurance through their employers, the court could order one of the parents to add the child to their plan.
If the parent hasn’t worked long enough to gain health benefits from the employer, there could be a process to ensure the child receives group benefits immediately when the parent finishes their waiting period.
Death or loss of someone covered by your health plan
If you’re listed on someone’s health coverage and they die, you’ll lose your health coverage. If someone who is listed as a dependent on your health coverage dies, it’s important to notify your insurer because your health insurance premiums could change.
Domestic abuse survivor
Domestic abuse survivors do not have to provide any form of documentation. They may fill out a form for a special enrollment period and enroll in a plan within 60 days of the request.
Spousal abandonment is when a spouse abandons or neglects their family without communicating or justifying their actions. To be eligible for a spousal abandonment case, your spouse has to have stopped supporting your family financially and have been gone for at least 6 months.
Changes In Your Employment and Finances
Job changes that affect your income
The change in your income may affect your health insurance. If you are on Medicaid and your income now exceeds the Medicaid limit, you may qualify for a special enrollment period.
If you lose a job and now bring in less income, you could be eligible for Medicaid assistance. Medicaid assistance is a federal and state program that provides health coverage to individuals, seniors, parents, and children.
Loss of employer-sponsored health insurance
If your health insurance was covered by your employer and you left or lost your job, you could be eligible for a special enrollment period. Bear in mind that if you voluntarily resign from your job, you may not be eligible for a special enrollment period.
Changes In Your Location
Moving to where different health plans are available
If you’re moving within the state and there are different health plans available, you may be qualified for a special enrollment period. You must have had prior health coverage before moving to be eligible.
Moving to where your health plan area has changed
Each state will have its own health plans that consist of both state-wide and local coverage. If you’re moving to a different state, this will count as a qualifying life event in the case that the other state doesn’t carry your current health plan.
Change in citizenship or status of lawful residency
After you become a U.S. citizen or gain the status of lawful residency, you have 60 days to enroll in health insurance through the exchange and off-exchange. After your enrollment, your health coverage will begin the following month. For example, if you enroll on June 5, your health coverage is effective beginning July 1.
Release from incarceration
Incarceration means serving a term in prison. You may be suspended from your existing health insurance if placed in jail. If your income is up to 138% of the federal poverty level, you may apply for Medicaid. Medicaid does not pay for the cost of care while you’re in jail, but it could offer you more care quickly after your term ends. After your release from incarceration, you have 60 days to enroll in health insurance.
Changes In Your Age
Turning 26 and losing parental coverage
Your health coverage may end on the last day of the month when you turn 26 if you’re listed as a dependent under your parent’s health insurance. Some plans may allow you to stay on your parent’s plans until the end of the year. For example, if you turn 26 on June 5, your coverage may end by the end of June or December 31, depending on the policy.
Turning 65 and becoming eligible for Medicare
Original Medicare is a federal health insurance program that consists of Part A (Hospital Insurance) and Part B (Medical Insurance). Your initial enrollment period begins three months before your 65th birthday, the month of your birthday, and three months after your birthday.
You may automatically be signed up for Medicare Part A, but you must sign up for Medicare Part B through your local Social Security office. If you don’t sign up for Medicare Part B within this period, you could face a penalty of up to 10% each year for future Part B premiums.
If you have existing health coverage through your employer or spouse’s employer, you may qualify for a special enrollment period. This special enrollment period allows you to delay signing up for Medicare Part B without any penalties. After your current health coverage ends, you may get 8 months from your special enrollment to enroll in a Medicare Part B plan.
To become eligible for Medicare, you must be 65 and older, disabled, or diagnosed with End-Stage Renal Disease.
Medicare vs. Traditional Private Health Insurance
You may have both Medicare and a traditional private health plan simultaneously. If you have both, your private health plan is the primary payer, and Medicare may be the secondary payer. A primary payer pays the health claim first. If there are remaining costs left over, the secondary payer may pick up the rest of the cost.
You may also have Medicare alongside group health insurance. However, in this case, Medicare is the primary payer, and your group health insurance is the secondary payer.
Having either a group health plan or private health plan alongside Medicare may be beneficial, as it could minimize how much your out-of-pocket costs could amount to.
Changes In Your Current Health Insurance
Losing minimum essential coverage
In the case that you involuntarily lose your health coverage, you’re eligible for a special enrollment period. This could include losing coverage through a job, individual or group health plans that end during the year, or student health plans ending.
Losing COBRA coverage
The COBRA Act of 1985 is a federal law that allows you to keep your employer-based health coverage for 18 months if you lose your job. After the 18 months are up, you may have a 60-day special enrollment period to enroll in your own health insurance.
Grandfathered or grandmothered plan that operates outside usual cycles
Grandfathered plans are health insurance policies purchased on or before March 23, 2010, and may not be changed in any type of way, meaning the benefits and cost of the insurance must remain the same. Grandmothered plans are non-grandfathered plans that took place from 2010 to the end of 2013 and are not fully compliant with the Affordable Care Act.
If you have a grandfathered or grandmothered plan, you may continue to keep it. The only way you may lose a grandmothered or grandfathered plan is if there are significant changes to the policy itself.
Other Eligible Cases for Special Enrollment Period
If you’re an American Indian or Alaska Native, you could be eligible for government healthcare assistance. There is no special enrollment period specifically for American Indians or Alaska Natives. Instead, as a tribal member, you may be eligible for a special enrollment period if:
- You’re enrolled in group health insurance
- Your current group health insurance ends
- You’re serving as a volunteer overseas
Medicaid and/or CHIP
Medicaid and the Children’s Health Insurance Program (CHIP) is a federal and state healthcare program designed to assist low-income Americans. The difference is that Medicaid assists adults and CHIP assists children, and you may enroll at any time with either program.
If you lose eligibility for Medicaid or CHIP, this could be a qualifying life event to enroll in another health insurance policy.
How a Qualifying Life Event for Health Insurance Works
A qualifying life event triggers a special enrollment period that allows you to enroll in a health insurance policy outside of the normal enrollment period. Without a SEP, you would have to wait a year without health insurance to either change or sign up for health coverage.
Starting from the day of your qualifying life event, you may have 60 days to enroll in a health insurance policy without facing any penalties. When filing for a SEP, you may be expected to show documentation of your life events, such as:
- Utility bills
- Rental or mortgage documents
- Homeowners insurance
A full list of documents can be found on Healthcare.gov.
Do Qualifying Life Events Expire?
Depending on your qualifying life event, you may have 60 days before or 60 days after to enroll in a new health plan. Individuals who have delayed their Medicare enrollment due to existing health coverage may have up to 8 months to enroll in Medicare Part B after their health plan ends.
To take advantage of a QLE for a Special Enrollment Period, you must have proof of your qualifying life event within 30 days. If you wait too long to take action, you may no longer be eligible for a qualifying life event.
What If You Need to Change Coverage But Do Not Have a Qualifying Life Event?
If you do not have a qualifying life event, you may not be eligible for a special enrollment period, but there are other options available that you may use to ensure that you have health coverage, such as waiting for the next enrollment period or applying for a short-term health policy.
Short-term health insurance gives you temporary coverage when you lose your permanent health coverage. It also provides emergency coverage for those who change jobs, attend an out-of-state college, or are waiting for the annual enrollment period to enroll again.
For those who are on a Medicare supplement plan, you may change your plan at any time of the year if you’re in good health and meet eligibility requirements. If you have a Medicare Advantage plan and didn’t make any changes from October 15 through December 7, you may change your plan January 7 through March 31.