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Qualifying Events in Health Insurance

Open enrollment for health insurance plans in the individual market has ended but there’s still an opportunity to make changes to your 2021 insurance coverage – if you have a qualifying life event.

Health insurance plans limit when you can enroll or change coverage to the open enrollment period. However, under certain circumstances, you may be eligible for a special enrollment period. 

If you have a qualifying event, you can purchase health insurance or change your existing coverage without waiting until the next open enrollment. Otherwise, you’re required to maintain your insurance as is until the following enrollment period. 

What is Open Enrollment?

Each year, a window is provided to enroll in a health insurance plan through your employer, a state or federal insurance marketplace or directly through an insurance company. 

During open enrollment, you can make changes to your coverage or enroll in a new plan. Employers create their own enrollment windows.  A set open enrollment period is established for Individual health insurance purchased through a state insurance marketplace or directly from an insurance company. 

Most states have open enrollment periods between Nov. 1 and Dec. 15 although some states have longer open enrollment periods including, including California, Colorado, the District of Columbia, Massachusetts and New York.

What is a Special Enrollment Period?

A special enrollment period enables you to enroll or change health insurance policies outside the standard open enrollment period. A qualifying life event triggers a special enrollment period.

Special enrollment periods apply to qualified individual health policies purchased through both the state and federal health insurance exchanges and outside the exchanges through a broker or health insurance website. Employer-sponsored health plans also offer special enrollment periods.

If you experience a qualifying event, you have 60 days to select a plan or switch to a different plan. Typically, if you enroll by the 15th of the month, coverage is effective the first day of the following month. Employer-based plans are required to provide a special enrollment period of 30 days.

For certain qualifying life events such as marriage or birth of a child, you may be able to select a plan up to 60 days in advance. Consult your plan documents for specific dates.

If you don’t enroll or make changes within the 60 day period, you will have to wait for open enrollment.

What is a Qualifying Life Event?

A qualifying event is a life change or circumstance affecting your health insurance needs or your qualification for existing health insurance or subsidies. 

Qualifying life events may entitle you to a special enrollment period to purchase health insurance without waiting for the open enrollment period. 

There are four types of qualifying events: loss of health coverage, changes in household, changes in residence, offer of new health benefit and other qualifying events. 

Here are some examples of qualifying events by category. To confirm your qualifying life event is eligible for a special enrollment period, consult your plan documents or a complete list is available on HealthCare.Gov.

  • Loss of health coverage 
  • Losing job-based coverage 
    • No longer eligible for Medicaid or Children’s Health Insurance Program (CHIP)
    • Losing eligibility in Medicare
    • Turning 26 and losing coverage through a parent’s plan
  • Change in household 
    • Getting married or divorced
    • Having a baby or adopting a child
    • Death of a family member on your individual insurance plan
  • Change in residence
    • Moving to a new home in a new zip code or county
    • Moving to the U.S. from a foreign country or U.S. territory
    • Student moving to or from the place you attend school
    • Moving to or from a shelter or other transitional housing
    • A seasonal worker moving to a new place to live and work
  • Other qualifying events
    • As of January 1, 2021, Becoming newly eligible for Qualified Small Health Reimbursement Arrangement (QSEHRA) or Individual Coverage Health Reimbursement Arrangement (ICHRA)
    • Gaining membership in a federally recognized tribe or status as an Alaska Native Claims Settlement Act (ANCSA) Corporation shareholder
    • Becoming newly eligible for Marketplace coverage because you became a U.S. citizen
    • Leaving incarceration (jail or prison)
    • AmeriCorps VISTA members starting or ending their service

Just experiencing a qualifying event does not automatically make you eligible for a special enrollment period. To be considered a qualifying event, it must alter your health plan benefits. For example, if you get married but you aren’t adding your spouse to your health plan, you are not allowed a special enrollment period.

In addition to experiencing a qualifying event, there are certain circumstances in which you may be eligible for a special enrollment period. These situations are known as “complex issues” and include an unexpected hospitalization or a natural disaster such as hurricanes, flooding or earthquakes. Complex issues are evaluated on a case-by-case basis.

What is the Process to Apply for a Special Enrollment Period?

If you have an insurance plan through the Marketplace, you can check your eligibility and apply for a special enrollment period on HealthCare.Gov or through your state’s marketplace.

 If you purchased a plan outside of the Marketplace or have an employer-based plan, you should check with your insurance company about their process. 

Depending on your qualifying event, you may need to provide documentation to verify your situation. Your coverage won’s start until you receive approval. You will be asked for this documentation once you submit your application. 

Documents depend on your qualifying event and may include:

  • Marriage certificate
  • Divorce papers 
  • Birth certificate
  • Adoption paperwork
  • Proof of prior insurance 60 days before the qualifying event.
  • Utility bills, mortgage documents or homeowner’s insurance policy 

You have 30 days after enrolling in a plan to submit the requested information but you should submit as soon as possible to avoid a delay. Your coverage will not begin until your eligibility is confirmed and you pay your first premium.

For Marketplace plans, you can submit documents by uploading or sending them by mail. upload documents or send them by mail.

If you become eligible for Medicaid or CHIP, you don’t need to apply for a special enrollment period. You can enroll at any time.

What Happens After Submitting Documentation?

Several weeks after submitting your documentation, you and your insurance company will be notified about whether your eligibility has been confirmed.

Once you receive confirmation, you must pay your first premium to the insurance company, not the Health Insurance Marketplace. Your coverage will start as soon as the payment is processed.

Confirmation delays may prevent you from using your plan after the coverage start date. You may need to pay premiums for previous months in order to receive retroactive coverage.

If you are not confirmed for a special enrollment period, you can appeal the decision by submitting alternate documentation. If the appeal is rejected, you will need to wait for open enrollment.

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