Different Qualifying Life Events for a Special Enrollment Period

Individual and Family Health Plans

special enrollment period

Special Enrollment Period and Qualifying Life Events

To enroll in health insurance plan outside the annual enrollment period, which takes place between November 1st and December 15th, you need to have a Special Enrollment Period.  A Special Enrollment Period (SEP) is a period during which individuals and their entire household can shop for and enroll in a health insurance plan (or change to a different plan if already enrolled). An SEP can occur at any time during the year, including during the Open Enrollment Period. This information below outlines all the possible triggering events and the specific enrollment details associated with each, as implemented in accordance with State and Federal regulations.

Key Terms:

Qualified Individual:

A person who meets the criteria to enroll through the Marketplace (Healthcare.gov, Connect for health Colorado, Covered California, or Pennie)- specifically a person who is not incarcerated, has a lawfully present immigration stats, and resides in the state where the Marketplace operates.

Dependent:

A person eligible to enroll in a health plan with a qualified individual under the terms of the health plan. This can include a spouse, child, or other family member, and does not necessarily have to be a tax dependent.

Requirement of Prior Coverage:

Eligibility for certain SEPs require that the person experiencing a qualifying event to be enrolled in Minimum Essential Coverage (MEC) prior to the qualifying event to trigger the SEP. Some SEPs require that the person be enrolled in MEC for at least one day in the 60 days prior to the qualifying event (or have lived abroad) to be eligible for the SEP. other SEPs are only triggered by people currently enrolled in a QHP. Not every SEP has a requirement of prior coverage.

Regular Coverage Effective Date:

For SEPs with regular coverage effective dates, coverage is effective the first day of the following month if a plan is selected between the 1st and the 15, or the first day of the second following month is a plan is selected between eh 16th and the last day of the month.

Qualifying Life Events for a Special Enrollment Period:

  • Loss of Minimum Essential Coverage
  • Change in Households size
    • Marriage
    • Birth / Adoption / Court Order
    • Divorce / Legal Separation
  • Change in Primary Place of Living (Must have a different Zip Code at least)
  • Changes in Eligibility
  • American Indian or Alaska Native
  • Enrollment or plan Error
  • Uncommon Scenarios (other, case by case evaluation) (contact us for a consult)

Proof of Qualifying Life Event:

Remember the insurance company or the Marketplace will ask for a proof supporting the qualifying life event to have an SEP to enroll in a health plan. If the qualifying life event is marriage, then a copy of the marriage certificate needs to be provided. Furthermore, if the QLE is due to changes in Eligibility then a document needs to be presented showing the changes. For instance, John was enrolled in Medicaid due to low income. John received a raise and thus higher income will qualify him to enroll in a health plan since he is no longer eligible for Medicaid.

What type of insurance can I get if I don’t have any of the above Qualifying Life Events?

If you don’t have a valid QLE that allows for a Special Enrollment period, then you have alternative options. 

  1. You can sign up for a Short Term Health Insurance, as long as it is allowed in your state. Check this article for states that bans the sale of Short Term health insurance. 
  2. You can enroll in an Indemnity Plans that reimburse you a set dollar amount per medical claim. Carriers like UHC, National General, and Pivot Health offer these plans. 
  3. Consult with an insurance agent or broker to discuss available options in your area. Our agents are here to help al the time, contact us to learn more.

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