What Is  a Qualifying Life Event?

by Team eLocal
illustration of a two people discussing insurance options

For most people choosing health insurance coverage, the selections are locked in until the next open enrollment period. For some, a qualifying life event changes that dynamic and provides an opportunity to make adjustments in the moment.

What Is a Qualifying Life Event for Insurance?

Insurance companies classify qualifying life events as life-changing moments that significantly change the health insurance needs of an individual and their family. Not all health insurance policies will recognize qualifying life events. Those that are Affordable Care Act-compliant typically recognize standard qualifying events, while short-term medical plans prohibit coverage changes for any reason.

What Is a Special Enrollment Period?

For those with insurance that recognizes qualifying life events, one of the applicable life changes triggers a special enrollment period. This is a set period of time in which the insured can alter their health insurance to fit the new situation. Special enrollment periods typically last 60 days before or after the qualifying event, which results in a change in family status. Qualified life events must be proven with documentation that is sent within 30 days of selecting a new plan. Although the new plan takes effect immediately, it cannot be used until eligibility is confirmed.

What Are Some Examples of Qualifying Life Events?

Most health insurance companies that provide marketplace or group coverage use the list of qualifying events established by the IRS:

Loss of Health Care Coverage

  • Losing eligibility for coverage by Medicaid, Medicare or CHIP
  • Loss of employment-based coverage
  • Aging out of coverage through a parent's plan
  • Loss of coverage for any reason other than failing to pay premiums

Household Changes

  • Change in marital status (including separation)
  • Change in dependents (pregnancy, adoption, etc.)
  • Loss of coverage due to the death of the primary insured

Residence Changes

  • Relocating to a different coverage area
  • School transfers for students
  • Employment travel outside the coverage area

Additional Qualifying Life Events

  • Income changes that affect coverage eligibility
  • Gaining U.S. citizenship
  • Incarceration release
  • Loss of coverage due to the retirement of the primary insured
  • Change in jobs for a spouse who is the primary insured

It's important to note that when the insured elects to continue health coverage through COBRA after a qualifying event, canceling COBRA doesn't count as a qualifying event, and the special enrollment period may be missed.

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