Qualifying Life Events: When life changes, your benefits might be able to, too
It’s impossible to predict the future (for now), so how do you ensure you and your loved ones are insured in case of a surprise?
A qualifying life event, or QLE, is a significant life change that allows you to make adjustments to your health insurance coverage and certain benefits outside of the regular enrollment period. Qualifying life events include losing health insurance, getting married or adding a child to your family, or making a big move.
If you go through a QLE, you’ll usually have a limited window to make changes to your plan or enroll in a new one, also known as a Special Enrollment Period. Once your Special Enrollment Period is up, your window to make adjustments has closed until you experience another QLE or the next annual enrollment period—whichever comes first.
Since every situation is unique, your employer and HR department are great resources for helping you navigate your specific QLE process. If you have other questions, your health insurance provider can help fill in any gaps.
Because you’ll have a limited amount of time to change your coverage under the Special Enrollment Period, it can help to have all the info you need before you actually need it. Here is some key information to keep in your back pocket.
How do you know if you’ve gone through a qualifying life event?
Not all significant changes you go through will fall under the QLE umbrella. The most common qualifying life events include:
Loss of health insurance coverage
If you lose your health coverage involuntarily, meaning you didn’t cancel the plan yourself or miss necessary payments, then you’re likely eligible for a Special Enrollment Period. Maybe you were on a family member’s insurance and aren’t eligible for their coverage anymore, or you’re no longer employed and lost your health insurance as a result. Whatever the case, if you lost your coverage by no fault of your own, then there’s a good chance you’ve experienced a QLE.
In order to qualify, the lapse in coverage had to have taken place in the past 60 days or will take place within the next 60 days.
In the case that you lose your employer-sponsored health coverage, you can enroll in the Consolidated Omnibus Budget Reconciliation Act (COBRA) or apply for Marketplace coverage.
If you opt for COBRA, you’ll have the same medical, dental, and vision benefits, but your employer may no longer cover their portion of the premium. You can drop your COBRA coverage at any time, but opting out of it won’t trigger another QLE.
Changes in household size
A change in the number of people eligible for coverage in your household is another common QLE. This might happen if you or someone in your home gets married, divorced, or legally separated. It could also be that you added a child to your home or someone on your plan has passed away.
In most of these cases, you’ll have a limited window from the life event to choose a new policy — often 30 to 60 days. Your new coverage will typically begin either on the first day of the next month or be applied retroactively to the day of the event.
Relocation
Making a move? If you’re planning on a major relocation to a new state, a small jump to a new county or zip code, moving to the US from a foreign country, or moving to or from transitional housing, you may be eligible for a Special Enrollment Period.
If you’re only moving for a short-term reason, meaning you don’t intend to permanently move to a new location (think a month or two of extended medical care in a different state), then you won’t qualify for a Special Enrollment Period. The exact amount of time that “short-term” refers to will vary based on your specific plan.
Keep in mind that in most cases, you’ll need to provide proof that you had coverage at some point in the 60 days before you moved.
Other life events
Life can be unpredictable, and the categories above can’t account for every big change that might come up. Here are a few other events that might significantly change your health coverage needs and qualify you for a Special Enrollment Period.
Becoming a US citizen
Qualifying for Medicare
Aging out of a parent or guardians health plan by turning 26
Income changes that affect your coverage
Beginning or ending servicing as an AmeriCorps State/National, VISTA, or NCCC member
Becoming a member of a federally recognized tribe or gaining status as an Alaska Native Claims Settlement Act Corporation shareholder
Leaving incarceration
To learn more about what counts as a qualifying life event, you can check out the official list on HealthCare.gov.
What happens if you go through a QLE?
Big life changes, whether they’re good or bad, can be stressful. First, you’ll want to make sure that your life event qualifies for a Special Enrollment Period — you can do this by completing a screening through HealthCare.gov.
If you qualify, you’ll need to apply for a Special Enrollment Period. You can usually initiate this process by reaching out to your HR department, although in some cases you may need to contact your insurance provider. The application is straightforward and just means proving your QLE through official documentation, as well as proof that you previously had health insurance. Some of these documents might include:
Marriage certificate or divorce/legal separation papers
Birth certificate, hospital certificate, legal guardianship document, or adoption papers
Mortgage statements, leasing papers, or USPS change of address confirmation
Coverage termination notice from your employer or insurance provider
Have a question based on your specific life change? Your HR team can be a great resource and give you insight and examples of what you’ll need — or how to submit a letter or explanation if you don’t have the documents that are typically required.
Remember: you’ll usually only have 30-60 days after your event or loss of coverage to make any updates to your plan, so be sure to call or message your HR department or insurance provider as soon as you can. From there, your new or updated coverage will likely begin on the first day of the following month.
What if you don’t qualify for a Special Enrollment Period?
If you have what you believe might be a qualifying life event, apply for a Special Enrollment Period, and are told you don’t qualify, you may be wondering what to do.
The good news is that you can submit an appeal within 90 days of the date listed on your Eligibility Notice. You can file your appeal online or mail it to the Health Insurance Marketplace. If your health is at risk, you can also file for an expedited appeal.
If you still don’t qualify, you have a few options. As always, you can wait until the next open enrollment period to make changes to your coverage.
Lastly, you can look into a government-sponsored program like Medicaid or the Children’s Health Insurance Program (CHIP). For these plans, you’ll have to meet certain income and eligibility requirements, which you can learn more about here:
ALEX
Fun fact: Even though that new haircut looks good enough to be insured, it does not count as a qualifying life event.