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What are Qualifying Life Events?

Understanding when and how to use your Special Enrollment Period (SEP)

Reviewed by: Ed McClane, Licensed Insurance Agent.

Father, expecting mother and young child packing for a move.

Key Takeaways

  • A Qualifying Life Event (QLE) allows you to purchase health insurance or change coverage outside of the Open Enrollment PeriodOpen Enrollment is the annual time period when individuals enrolled in Medicare Advantage plans can make a one-time plan change to any other Medicare Advantage, Medicare Advantage Part D, Part D plan or switch to Original Medicare. Medicare Open Enrollment is from January 1 to March 31. for the current plan year.

  • A special enrollment period follows significant life events like childbirth or adoption, marriage or divorce, unemployment, or unexpected health coverage loss.

  • The Special Enrollment Period allows you to make changes to your existing coverage or enroll for the first time.

What is a Qualifying Life Event?

There are four main types of qualifying life events: loss of health insurance coverage, household changes, moving and other circumstances. Here are some examples:

Loss of Coverage

  • Losing job-based coverage (voluntary or involuntary)
  • Losing eligibility for MedicareOriginal Medicare (Parts A and B) is fee-for-service health insurance available to all Americans aged 65 and older and some individuals with disabilities. Original Medicare is provided by the federal government and is made up of two parts: Part A (hospital insurance) and Part B (medical insurance)., Medicaid or CHIP
  • Losing insurance through a family member
  • Aging off of a parent’s plan at 26

Household Changes

  • Getting married
  • Getting divorced or legally separated
  • Having or adopting a baby
  • Death in the family

Moving

  • Moving to a different ZIP code
  • Moving from outside the U.S.
  • Students moving to or from college, or seasonal workers moving to where they live or work
  • Moving to or from a shelter

Other

  • Gaining U.S. citizenship
  • Substantial changes in income
  • Errors with an original enrollment
  • Leaving jail

What is a Special Enrollment Period?

If you have a Qualifying Life Event, you are eligible for the Special Enrollment Period. The period allows you to make changes to your current health insurance plan, or add your spouse or children to your health coverage. Your Special Enrollment Period usually starts 60 days [1] from the date of your event, when you can make changes to your existing health insurance coverage.

Are there exceptions to Qualifying Life Events?

There are some “complex issues” [2] that may allow you to buy a medical health plan outside of Open Enrollment.

  • Exception circumstances: You experienced a medical condition or natural disaster that prevented you from applying during open enrollment.
  • Misinformation or misrepresentation: You enrolled in the wrong plan because of misinformation, misrepresentation, misconduct or inaction from a health insurance company.
  • Enrollment error: Your health insurance application was rejected because of missing data or technical issues.
  • Medicaid or CHIP exceptions: You were incorrectly advised you were eligible for Medicaid or the Children’s Health Insurance Program (CHIP).
  • Domestic abuse victims: You want to enroll in a separate health plan from your abuser. You may be eligible to receive a tax subsidy separately, and your dependents may also be eligible.

If you think you might qualify for special enrollment, GoHealth’s licensed insurance agents can determine your eligibility and help you find and enroll in a health plan that’s right for you.

FAQs

Do I have to prove eligibility for the Special Enrollment Period?

If you are applying through the Federal Marketplace [3] or Healthcare.gov, you may be asked to provide documents to prove your eligibility for a Special Enrollment Period. You will receive more information about what is needed after submitting your application. You generally have 30 days to send the information, and your coverage won’t start until you provide all the necessary documents. However, there may be some cases where you don’t need to submit any documents. If your eligibility is not approved, your policy may be canceled.

What if my request for the Special Enrollment Period is denied, or I don’t qualify?

If your request for special enrollment is denied and you believe you experienced a Qualifying Life Event, you can file an appeal. You should include any eligibility documentation or notice that you received.

If you miss Open Enrollment and you don’t qualify for special enrollment, consider looking into whether you are eligible for Medicaid or CHIP. You can enroll at any time as long as you qualify. Medicaid is designed for low-income households, while CHIP offers coverage for children with lower costs.

Does voluntarily dropping your health insurance coverage count as a qualifying event?

Although many situations make you eligible for a Special Enrollment Period, voluntary termination of a health plan is not considered a loss of coverage. You won’t qualify for a Special Enrollment Period if you choose to drop coverage, and you will have to wait until the annual Open Enrollment Period.

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