What is a qualifying life event for health insurance?

If you’ve recently gotten married or had a baby, you’re probably wondering what to do about changing your health insurance plan. Significant changes like this can affect your eligibility for health insurance. Let’s take a look at qualifying life events for Affordable Care Act (ACA) plans and how they impact when you’re able to apply for health insurance.   

What is a qualifying life event for health insurance?

Qualifying life events (QLEs) are changes to your circumstances that allow you to enroll in health insurance outside of annual open enrollment periods. The ACA defines qualifying events as significant life changes that give someone an immediate need for health insurance, allowing them to enroll or make other changes to their insurance in a Special Enrollment Period. Here are some of the most common qualifying life events that give someone the ability to choose a new health insurance plan or make other changes to their plan outside open enrollment periods.   

Note: Medicare and employer coverage have unique rules, qualifying life events, their own open enrollment periods. The following are qualifying life events for ACA plans.

Household changes

Significant changes to your household could qualify you for a Special Enrollment Period where you’re allowed to enroll in healthcare outside the normal enrollment timeframe. If you or someone in your home has gotten married, had a baby, adopted a baby, or placed a child for foster care in the last 60 days, you’ll qualify for open enrollment.

If you’ve gotten divorced or legally separated in the last 60 days and lost health insurance, you’ll qualify for a Special Enrollment Period. The same is true if you or anyone in your household loses health insurance in the past 60 days, or expects to lose health insurance in the next 60 days. In the unfortunate event that someone on your healthcare plan dies and your eligibility for that plan changes, you’ll qualify for a Special Enrollment Period that allows you to find new healthcare coverage. 

Residency changes

Changes in residency often allow people to qualify for a Special Enrollment Period. If you are moving into a new zip code or county; into the U.S. from a foreign country; students moving to or away from school; seasonal workers moving to or away from work; or to or from a shelter or transitional housing, you’ll most likely qualify for a Special Enrollment Period. Moving somewhere only for medical treatment or vacation does not qualify.

You must have had qualifying health insurance for at least one day in the 60 days before your move to qualify for a Special Enrollment Period.  However, you don’t need to provide confirmation if you’re moving from a foreign country or U.S. territory.

Loss of health insurance 

If you or someone in your household loses or is expecting to lose health coverage in the next 60 days, you may qualify for a Special Enrollment Period. The health insurance policy you’re about to lose must check one or more of the following boxes for you to be eligible for a Special Enrollment Period:

• You no longer qualify as a dependent under your parent or guardian’s health insurance plan.
• You or a family member, spouse, or parent has quit, been laid off, or fired from their job, resulting in a loss of health coverage through your employer or the employer of your family member, spouse, or parent. If you or your spouse starts a new job, you’ll most likely qualify for a Special Enrollment Period.    
• You’re losing Medicaid or Children’s Health Insurance Program (CHIP) coverage due to something like a change in your household income.  
• You’re no longer eligible for a student health plan.
• Your current plan is being discontinued. 

Note: Voluntary loss of coverage is not considered a qualifying life event. 

Other exceptional circumstances

You may qualify for a Special Enrollment Period if you are:

• Starting or ending service as an AmeriCorps member
• Becoming a U.S. citizen
• Leaving incarceration
• Becoming an Alaska Native member or member of a federally recognized tribe

If you or your dependents are victims of domestic abuse or spousal abandonment, you may qualify for a Special Enrollment Period. The National Domestic Violence hotline’s phone number is 1-800-799-7233. They can offer resources to help you and can provide advice on how to find new health insurance. You can also refer to healthcare.gov or your state marketplace, or consider applying to Medicaid.

As far as COVID-19 is concerned, it’s not a qualifying life event in itself. Eleven states, including D.C., have opened Special Enrollment Periods, but the other 38 states haven’t. If you live in one of these 38 states, you’ll have to check if you have a qualifying life event, says Susan Lyon, Media and Partnerships Manager at Health Sherpa. 

See a full list of qualifying life events on this SEP list.

What does not qualify?

Sometimes it’s hard to determine what life events will qualify you for a Special Enrollment Period. You do not qualify for a Special Enrollment Period if you:

• Moved somewhere solely for medical treatment.
• Are staying somewhere for an extended vacation.
• Lose your health coverage because you didn’t pay your premium. 
• Are dependent on a parent or guardian’s healthcare plan and you voluntarily drop the coverage. You have to age out at 26 to be eligible for a Special Enrollment Period. Otherwise, you’ll have to wait until an open enrollment period.
• Will remain eligible for your current healthcare and benefits, even if you’ve divorced or lost a family member.  

How long is the Special Enrollment Period? 

You’ll have 60 days following your qualifying life event to enroll in a healthcare plan. If you don’t enroll during this timeframe, you may have to wait until the next open enrollment period. 

ACA open enrollment is a 45-day timeframe in which you can change your health insurance or sign up for a new plan. With several exceptions, which vary by state, open enrollment typically lasts from November 1 until mid-December each year. 

So if you have a qualifying life event in March, for example, and don’t use your Special Enrollment Period to get health insurance, you’ll probably have to wait until November to enroll in coverage, which wouldn’t begin to cover you until January 1st. Keeping track of when a qualifying event happens ensures you have adequate healthcare coverage at all times.   

Next steps

After a qualifying life event and during the Special Enrollment Period, the next step is to pick a new plan that works best for you. You may need certain documents to help with with the application process, such as: 

• A marriage license
• Divorce, annulment, or legal separation papers 
• A birth certificate, adoption papers, or proof of legal guardianship paperwork
• Proof of prior qualifying health insurance
• Change of address confirmation

This list of documents is not comprehensive. The documentation you’ll need to sign up for health insurance through a Special Enrollment Period depends on your unique circumstances. The application process will tell you what you need to apply.

Some application processes give you 30 days after applying to send in any required documents that will prove your eligibility for a Special Enrollment Period. New coverage starts the day you apply for the plan. However, you won’t be able to use the health benefits until your eligibility is confirmed and you’ve paid your premium. You can still save receipts for out-of-pocket expenses to apply for retroactive reimbursement once your coverage is active.   

What if I don’t qualify for a Special Enrollment Period? What are my options?

If you don’t qualify for a Special Enrollment Period and have to wait for open enrollment that’s a long way away, you may be able to get short-term health insurance. Short-term health insurance plans provide coverage for a maximum of 364 days. This is especially helpful for people who need coverage during gaps in employment. 

You can also apply for Medicaid or the Children’s Health Insurance Plan (CHIP). You can apply to either of these programs at any time. COBRA is also a possibility. There are many options for finding healthcare when you need it most.