What Is a Qualifying Event for Special Enrollment?

What Is a Qualifying Event for Special Enrollment?

A qualifying life event is one that satisfies the criteria for the special enrollment period; examples include losing insurance or moving to a different state. The special enrollment period is intended to assist persons who, for a variety of reasons, might need to enroll in healthcare coverage outside of the typical open enrollment period.

You might consider special enrollment if you’ve found yourself in a situation where you require health insurance outside of the period from November 1 through January 15. However, in order to pursue it, you must have gone through at least one of the authorized qualifying events.

What is special enrollment?

A patient can alter their health care plan at this time of year without going through the open enrollment period (OEP). It was initially formed by President Barack Obama back in 2016, but it was speeded up after the most recent COVID-19 health crisis. After the pandemic passed, the public has continued to have the option.

The special enrollment period acknowledges that unexpected events in a person’s life occasionally necessitate them purchasing health insurance or making necessary adjustments to the plan they already have outside of the regular open enrollment period. The goal was to make it possible for the millions of Americans who lacked insurance at the time to obtain it.

Dependent on my Health Insurance Plan Who Can Be Added

You can either sign up for new insurance coverage or make adjustments to your current plan during the special enrollment period. It is made to give you the option to purchase new insurance or make changes to your current policy following the occurrence of a qualifying life event.

The individual may enroll in an ACA-compliant plan during a special enrollment period either on or off-exchange (we’ll discuss the distinction between these two words later). To qualify, you must have had a qualifying life event, and you must be able to prove that the event actually occurred.

What is a qualifying life event?

Most people are obliged to purchase insurance under the Patient Protection and Affordable Care Act during the Open Enrollment Period, which normally occurs at the end of each year. You can be qualified for a special enrollment period outside of the regular OEP if you have a qualifying life event.

Events in your life that qualify and make you eligible for a 60-day special enrollment period include the following.

The coverage loss

There is a significant probability that if you find yourself unexpectedly without health insurance, you have gone through a qualifying life event that could result in a special enrollment period. The following list includes some of the causes of loss of coverage that typically count as qualifying life events:

  • The Affordable Care Act permits children to continue being covered by their parents’ insurance until they become 26. This implies that many kids lose their insurance when they turn 26. As a result, they are qualified for an unique enrollment time to purchase insurance for themselves.
  • Losing Program Eligibility: Families and individuals who cannot afford health insurance on their own can receive it through public programs like Medicaid and SCHIP. You can lose eligibility if you currently rely on one of these programs but your income rises. In this situation, an unique enrollment period may be used to purchase insurance devoid of government support.
  • Loss of Coverage Source: The majority of employed people receive insurance through their places of employment, and many students do as well. Therefore, you require a specific enrollment time to replace such coverage in the event that you lose your employment, graduate, or stop attending school.

Find out if you are eligible for a special enrollment period if you find yourself suddenly without health insurance. Except when it’s due to loss of coverage, a special enrollment period is frequently triggered by loss of coverage for a variety of reasons.

Domestic developments

Events inside your home might have an impact on the amount of coverage you must purchase and the cost of it, in addition to developments that directly result in you losing coverage. These consist of:

  • Marriage and divorce—The start or end of a marriage frequently qualifies as a life event.
  • Having kids: You must provide insurance for children, whether you give birth to them or adopt them, thus this life event typically qualifies as one, necessitating a particular enrollment time.
  • Death: If a member of your family passes away, you will no longer need to provide for them but also won’t have access to their income to help with the cost of coverage. Because of these factors, the death of a person with whom you have a health insurance plan can qualify as a life event.

Consider how any changes to your household will impact your health insurance whenever one occurs. It’s possible that significant changes in your home, such the addition or deletion of a family member, will necessitate a special enrollment.

Residency shifts 

Regulations and availability of health insurance differ from state to state and even from county to county. So you can certainly count this change as a qualifying life event if you relocate anyplace in a different county or with a different zip code. If you’re a seasonal worker who alternates between your permanent residence and your place of employment, a student who alternates between school and home, or a person moving into or out of transitional housing, you may also be eligible for special enrollment.

Other qualifying life events

  • Joining an indigenous nation that has received federal recognition
  • Becoming a stakeholder in the Corporation for the Settlement of Alaska Native Claims
  • Encountering any income change that modifies your eligibility for coverage
  • Beginning or ending a term of AmeriCorps service
  • Obtaining US citizenship or another type of legal status that you previously lacked
  • Changing your status so that you can receive subsidies under the Affordable Care Act
  • Leaving a prison or a jail

We are dedicated to assisting you in obtaining the coverage you require at a cost you can afford, regardless of whether you go through any of these qualifying life events or are enrolling during the open enrollment period.

How soon after my qualifying event can I get coverage?

Within 60 days of the occurrence of a life-altering event, you may start the health insurance application procedure. In most cases, your coverage will begin in the month after you choose your preferred plan. Previously, if you wanted coverage to begin on the first of the next month, you had to submit your application by the 15th, but that’s no longer the case. HealthCare.gov will no longer need applications to be submitted by the 15th of the month starting in 2022.

Proof of your qualifying event must be provided

In most cases, you will need to present evidence if you think you have had a life-changing event that insurance would cover. This follows the precedent set in February 2016 by the US Department of Health and Human Services (HHS).

You would need to present this documents to the health insurance carrier when you apply for coverage because there is frequently paperwork linked with a qualifying life event (for example, a birth certificate, adoption papers, change of address, or marriage certificate).

Please be aware that HHS plans to start addressing this issue in 2023. For the time being, they will do away with the verification requirements for all SEPs besides loss of coverage.

off-exchange vs on-exchange Special enrollment

An “on-exchange plan” is one that you purchase through the marketplace, whether you do it on your own or with a broker or agent’s help. It is regarded as off-exchange if you buy it from the insurance provider directly. Off-exchange insurance can be purchased on your own or with a broker’s help.


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