What is a qualifying life event?

When the Affordable Care Act (ACA) went into effect, it ensured that anyone who applied for individual health insurance would get approved and enrolled. Open enrollment is the yearly timeframe when Americans can sign up for, renew, or adjust their health insurance plans.

However, if you experience a qualifying life event, you can trigger a special enrollment period (SEP) and sign up for health insurance outside of the open enrollment period.

In this article, we'll go over the qualifying life events that trigger a special enrollment period. We’ll also discuss what you need to do once your SEP starts.

In this blog post, you'll learn the following:

• What changes in your life situation count as qualifying life events.
• What additional cases may qualify you for a special enrollment period.
• How to apply for a special enrollment period after experiencing a life event.

What does a life event mean?

A qualifying life event is an event in your life that makes you eligible for a special enrollment period. This allows you to enroll in a health insurance plan outside of the annual open enrollment period that takes place at the end of the calendar year. A special enrollment period generally lasts 60 days before or after the qualifying life event.

Qualifying life events are beneficial because they prevent you from experiencing a gap in coverage if you lose your health insurance for a legitimate reason outside the standard open enrollment timeframe.

What are the four major life events?

While several major events can happen during your lifetime, only a handful qualify you for an SEP.

The four basic types of qualifying events are:

• Loss of health coverage
• Offer of a new health benefit
• Changes in household
• Changes in residence

Let's examine each of the events in the above categories in more detail.

1. Loss of health coverage

The first category is loss of health coverage. If you've previously had health insurance but lost it, that event will fall into this category.

Here are some examples of events that qualify as a loss of health insurance:

• Losing employer-sponsored coverage
• Losing COBRA coverage
• Losing individual health insurance coverage for a current plan you bought yourself
• Losing eligibility for coverage for Medicaid or the Children's Health Insurance Program¹ (CHIP)
• Losing eligibility for coverage for Medicare
• Losing coverage through a family member

We'll cover these loss of coverage events in more detail below.

Losing job-based coverage

If you experience a loss of coverage through your employer or a family member's company, you might qualify for a special enrollment period.

But, you won't qualify for an SEP if you lost your job-based health coverage because you voluntarily dropped it during the plan year or lost your coverage because you didn't pay your premium.

Common reasons for losing job-based coverage include:

• Your employer drops your current coverage
• You quit, or your employer fired you from a job where you had coverage
• You experienced a reduction in work hours that caused you to lose your job-based coverage
• Your job-based coverage doesn't qualify as minimum essential coverage (MEC), and you're eligible for a premium tax credit

Losing COBRA coverage

If you're losing COBRA continuation coverage because the coverage ran out or your former employer ends their contributions, causing you to pay the full cost of insurance, you qualify for a special enrollment period.

However, you won't qualify if you decide to end COBRA early and are paying the full benefit cost yourself. You also don’t qualify if you lose your COBRA coverage because you didn't pay your premiums.

Remember, you don't need a special enrollment period if you voluntarily end COBRA during open enrollment. You can drop your COBRA policy and enroll in an exchange policy at that time.

Losing individual health coverage for a plan or policy you bought yourself

If you lose your individual health coverage, you may be eligible for a special enrollment period during the following common events:

• Your insurance carrier stops offering your individual policy
• You lose eligibility for student health coverage
• You're no longer eligible for the policy because you've moved out of its service area
• Your individual or group health coverage year ends in the middle of the calendar year, and you don't renew it

Suppose you voluntarily dropped your current health plan or lost coverage because you didn't pay your health insurance premiums or provide the required documentation to the exchange. In that case, you won't qualify for a special enrollment period.

Losing eligibility for Medicaid or CHIP

If you lose eligibility for Medicaid or CHIP, you might qualify for a special enrollment period. This could be due to a change in household income, or you become ineligible for pregnancy-related life changes. Additionally, if your child ages off CHIP, you may qualify.

Losing eligibility for Medicare

You may access a special enrollment period if you lose Medicare Part A eligibility. You won't qualify, however, if you lose Medicare Parts B, C, or D only or if you lose Medicare Part A because you didn't pay your premium.

Losing coverage through family circumstances

Losing coverage through a family member, such as a parent or spouse, also qualifies you for a special enrollment period.

This could happen if:

• You turn 26 and lose your dependent status
• Your family member's employer plan cuts health coverage for dependents
• Your family member dies
• You divorce or legally separate from the spouse through whom you have health insurance

You won't qualify for a special enrollment period if you voluntarily drop your dependent coverage. Similarly, you won't qualify for coverage if neither you nor your family member pays the premium.

2. Offer of new health benefit

The second category of qualifying life events is if your employer offers you a new health benefit. If you've become newly eligible for a health reimbursement arrangement (HRA), such as a qualified small employer HRA (QSEHRA) or an individual coverage HRA (ICHRA) outside of open enrollment, you'll have access to a 60-day special enrollment period.

During this time, you can pick out a qualified health plan to receive tax-free reimbursement through your new HRA. If your employer offers your HRA through PeopleKeep, you can access expert help and shop for a policy right from your dashboard.

3. Changes in household

Next, let's look at the changes in your household that can qualify you for a special enrollment period. As your family grows or shrinks over time, you'll likely need to review your coverage options.

Qualifying changes in the household include:

• Getting married
  • If you've gotten married in the past 60 days, you can pick a policy through an SEP
• Having a baby, adopting a child, or placing a child in foster care
  • Apply for coverage within 60 days of having a newborn child, adopting a child, or placing a child in foster care, and your coverage will be retroactive to the day of the event
• Getting a divorce or legal separation and losing health insurance
  • You only qualify for a special enrollment period if divorcing or legally separating from your spouse caused you to lose health insurance
• Death of spouse or dependent listed on your individual health insurance policy
  • If someone on your policy dies and, as a result, you're no longer eligible for your policy, you'll qualify for a special enrollment period

4. Changes in residence

The last major category of qualifying life events is a change in residence. The health insurance marketplace and price of policies vary from state to state and by rating area. So, moving may qualify you for a special enrollment period to sign up for a new policy.

Qualifying changes in residence include:

• Moving to a new home in a new ZIP code or county (if it's outside your plan’s service area)
• Moving to the United States from a foreign country or U.S. territory
• Moving to or from the place you attend school if you're a student
• Moving to or from the place you both live and work, if you're a seasonal worker
• Moving to or from a shelter or other transitional housing

Other cases that may qualify you for a special enrollment period

While the above life events are a sure way to qualify for a special enrollment period, other special circumstances may also allow you to sign up for a health insurance policy outside the open enrollment period.

For example, you might also qualify for an SEP if:

• You join a federally recognized tribe
• You become a shareholder in an Alaska Native Claims Settlement Act (ANCSA) Corporation
• You begin or complete your service with AmeriCorps State, AmeriCorps National, VISTA, or NCCC

Here's a list of some additional circumstances that may open a special enrollment window for you.

1. Experiencing an “exceptional circumstance”

You're entitled to a special enrollment period if you face a serious medical condition or natural disaster that kept you from enrolling during open enrollment.

Qualifying examples include:

• Unexpected hospitalization
• Temporary cognitive disability
• A natural disaster like an earthquake, massive flooding, or a hurricane

2. Experiencing an enrollment or policy information display error

You're entitled to a special enrollment period if someone working in an official capacity kept you from enrolling in a policy, enrolling in the right policy, or getting the premium tax credit or cost-sharing reduction you were eligible for.

Potential individuals or groups in error could be an insurance company, an exchange navigator, or an insurance agent or broker. Misinformation, misrepresentation, misconduct, or inaction all qualify as enrollment or agency errors.

You're also entitled to a special enrollment period if you experienced a technical error when applying for coverage on your public health exchange. If you saw an error message when completing the online application that prevented you from enrolling in a policy or your carrier from receiving your enrollment information, you can access an SEP.

Similarly, if incorrect policy data—such as benefit or cost-sharing information—was displayed on the exchange when you selected the policy, you'll qualify for an SEP.

3. Previously living in a state without Medicaid expansion, and you're now eligible to pay for insurance due to income or a move

If you lived in a state that hasn't expanded Medicaid and you weren't eligible because your income was too low, you can qualify for a special enrollment period.

This situation applies if you moved or had an increase in household income that makes you newly eligible for Medicaid or advance payments of your premium tax credit within the last 60 days.

4. Being determined ineligible for Medicaid or CHIP

If you applied for Medicaid or CHIP during the open enrollment period and were deemed ineligible after open enrollment ended, you may qualify for a special enrollment period. This is true whether you applied directly through your local exchange, state Medicaid, or CHIP agency.

5. Gaining or becoming a dependent due to a child-support or other court order

You can access a special enrollment period if you either gained a new dependent or became a dependent of someone else due to a court order. Your comprehensive coverage will start on the effective date of the court order, even if you enroll in the policy up to 60 days afterward. In other words, your coverage would be retroactive to the date of the court order.

6. Experiencing domestic abuse or violence or spousal abandonment

The federal government grants special enrollment periods to survivors of domestic abuse and spousal abandonment who want to enroll in their own health policy. Any dependent, such as a dependent child, may also be eligible.

If you want to claim this special enrollment period, contact the Marketplace Call Center². If you're married to someone who abuses or abandons you, you can complete your application as if you're unmarried without facing penalties for misrepresenting your marital status. You'll also be able to collect a premium tax credit if you qualify based on your income.

7. Getting an appeal decision that's in your favor

You can enroll in or change policies if you file and win an appeal with your exchange after receiving an incorrect eligibility determination for a special enrollment period or an inaccurate coverage effective date.

8. Living at the federal poverty level

If you meet the federal poverty level criteria, you qualify for a low-income special enrollment period. This allows individuals facing financial difficulties to buy affordable health coverage outside the regular open enrollment period.

There are several online tools available to help you find out if you're eligible. The KFF's Health Insurance Marketplace Calculator³ is one option to find out if you qualify for a low-income special enrollment period.

Applying for a special enrollment period

If you've experienced one of the events above and want to apply for a special enrollment period, you'll need to do so through the federal Health Insurance Marketplace or your state-based exchange. How you apply depends on whether you've had a qualifying life event or another special circumstance.

If you have a qualifying life event, you can apply online. If you're unsure whether you qualify, HealthCare.gov⁴ or your state exchange can screen you by asking you questions⁵ about any of the events you've experienced that would open a special enrollment period.

After the Marketplace confirms your eligibility for coverage, you can either begin a new insurance application or log into your current account.

If you have a special circumstance rather than a qualifying life event, contact the Marketplace directly. You can reach the call center at 1-800-318-2596. The representative will ask about your situation and help you determine whether it qualifies you for a special enrollment period.

If your employer offers you a QSEHRA or ICHRA through PeopleKeep, you can shop for a policy right from your dashboard.

Filing an appeal

If your request for a special enrollment period is denied and you feel the decision is wrong, you can file an appeal.

To do so, select your state's appeal form through HealthCare.gov, download it, and fill it out. If possible, attach a copy of your eligibility determination notice and any other official notice you received.

Mail the appeal to:

Health Insurance Marketplace

Attn: Appeals

465 Industrial Blvd.

London, KY 40750-0061

Be sure to include the last four digits of the ZIP code, as this helps your appeal arrive faster.

Verifying your qualifying life event and enrolling in coverage

In most circumstances, you'll have 60 days following your qualifying life event or special circumstance to choose and enroll in a policy. As part of this process, you may need to verify your qualifying life event or special occasion through documentation.

You'll find out if you need to provide documentation before submitting your application for coverage. In some cases, you may not need to provide anything.

However, if you're asked, HealthCare.gov advises you to pick a policy first and submit documentation afterward. Once you choose a policy, you'll have 30 days to submit the verifying documents.

Details and instructions on the type of documents you need to submit will appear on your eligibility results screen and in a notice you can download or get in the mail.

Once you're ready to submit documents, upload them to HealthCare.gov or send photocopies of the original documents to:

Health Insurance Marketplace

Attn: Supporting Documentation

465 Industrial Blvd.

London, KY 40750-0001

In general, the documentation required depends on your qualifying life event. We'll go over two common reasons people qualify for a special enrollment period, the documentation they should submit, the timeline for submitting that coverage and picking a policy, and the time coverage starts once the first premium payment is made.

For all other documentation concerns and a complete list of acceptable documents to verify special enrollment periods, see HealthCare.gov.

How to verify that you've lost health coverage

Whether you already lost your health plan coverage or you will in the future, you'll have 60 days following the end of your coverage to choose a policy.

You'll need to submit documents verifying that your coverage has ended (or is coming to an end), along with the termination date. Acceptable documents may be notices from your previous insurance company or your employer. You should submit these within 30 days of choosing a policy.

If your coverage has ended, your new coverage will begin the first day of the month after you choose the new policy. If your coverage will end in the future, your new coverage will start the first day of the month after your old coverage ends and you choose a new policy.

Remember, your coverage won't go into effect unless your eligibility is confirmed and you make your first premium payment.

How to verify that you've moved to a new address and previously had insurance

If you're moving to a new address, you'll need to choose a policy within 60 days from the date you moved.

You'll also need to provide documents confirming your move and proof of former coverage. To verify your new address, you can submit government correspondence, utility bills, rental or mortgage documents, or homeowner's insurance. The documents must include your new address and the date of your move.

To verify your former health coverage, you must submit documents showing that you were covered at least one day during the 60 days before your move. These documents may be correspondence from your insurance company, employer, or health coverage provider. You don't need to provide this documentation if you're moving from a foreign country or U.S. territory.

You must submit all documents within 30 days of choosing a new policy.

If you choose a policy between the first and the fifteenth of the month, your coverage will start on the first day of the following month.

If you choose a policy between the sixteenth and the last day of the month, your coverage will start on the first day of the second month following policy selection. For example, if you choose a policy on July 20, your policy will go into effect on September 1.

What to do if you don't have a qualifying life event or special circumstance

If you want to sign up for health insurance outside of open enrollment and haven't experienced an event on this list, you'll have to wait until the next open enrollment period starts.

If you need coverage in the meantime, you can enroll in a short-term health insurance plan. These plans are only available in some states, but they can help you during emergencies while you wait for open enrollment.

Conclusion

Understanding the qualifying life events that allow you to choose a plan outside the regular open enrollment period empowers you to make changes to your health coverage when necessary.

If something happens that changes your health coverage status, following the guidelines in this article will help you understand if you can qualify for a special enrollment period.

This article was originally published on September 16, 2021. It was last updated on September 12, 2024.

1. HealthCare.gov
2. HealthCare.gov
3. KFF
4. HealthCare.gov
5. HealthCare.gov