What Is a Qualifying Life Event That Allows You to Apply Outside Open Enrollment
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UPDATED: Mar 31, 2020
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Most of us can only switch health insurers (or health insurance plans) during the Open Enrollment Period, which tends to take place between November 1st and December 15th of each year.
Some states may have extended deadlines, but for the majority of the U.S. you can expect a small window each year to make a health insurance change.
This differs from say auto insurance where you can switch insurers whenever you feel like it and get a refund for the unused premium.
Anyway, this OEP allows anyone to make a move to a different insurer or health plan for any reason, with plans sold during the 45-day period generally effective the following January 1st.
But what if you need to make a change and it’s not during that special 45-day window? Reading this guide will answer that question.
Switch Health Insurers During the Special Enrollment Period
Well, fortunately there exists what’s known as a “Special Enrollment Period,” or SEP, which allows changes throughout the year for a number of “qualifying life events,” or QLEs.
You’ve probably heard enough acronyms by now, and might even be a little confused. Let’s spell it out so you can make sense of it all.
Simply put, the qualifying life event allows you to circumvent the typical rules regarding switching health insurers so you can get on a new plan outside the yearly Open Enrollment Period.
There are four main types of qualifying life events, as spelled out by Healthcare.gov, including:
- Loss of health coverage
- Changes in household
- Changes in residence
- Other qualifying events
Let’s explore them in-depth so you can determine if you qualify for any of these qualifying events.
Note that if you do qualify you for a Special Enrollment Period, you may be required to provide documentation to prove eligibility. Fortunately, it’s possible to upload documents to avoid any delays.
Additionally, you typically get 60 days to enroll in a new plan following the date of the qualifying event.
Loss of Health Coverage
It’s possible to lose your health insurance coverage for a number of different reasons. One common one is losing your job, and health insurance plan along with it.
You may also lose your plan if it’s a student plan and you’re no longer eligible, or if you’re no longer on your parents’ plan because you moved and reside outside the service area.
Same goes for loss of eligibility for Medicaid, Medicare, CHIP, or lost coverage through a family member (divorce, death, no longer a dependent, etc.).
Another reason for loss of coverage could be because an individual or group health plan coverage year happens to be ending around the middle of the calendar year and you don’t renew it.
Or if your individual plan or Marketplace plan ceases to exist because it’s discontinued.
You probably get the gist by now – the important distinction here is that a plan can’t end because of failure to pay or provide documentation, or because you voluntarily decide to drop coverage.
Changes in Household
These ones are fairly cut and dry, and also pretty common. They include getting married and having a baby (including adopting a child or placing a child for foster care).
So a new mom might elect to switch health plans or health insurers, or a married couple might decide to do the same.
It’s also possible to qualify for the SEP if you got divorced or legally separated and lost your health insurance in the process. The key though is that you lost your coverage, which may not always be the case.
Lastly, if someone passes and that affects your health plan eligibility, it’s possible to make a switch.
Changes in Residence
Again, these are pretty straightforward reasons to avoid the 45-day Open Enrollment Period.
If you’ve moved or are moving to a new ZIP code, that may qualify you for a Special Enrollment Period.
Same goes for those moving to the U.S. from a foreign country or United States territory.
Another common scenario is a student either moving back home after university or traveling away to college.
Seasonal workers may also earn the exemption if they had to move for work, along with those who may have relocated via a shelter or transitional housing.
Other Qualifying Events
Lastly, we’ve got the “other” category, which includes things like leaving incarceration, becoming a U.S. citizen, or beginning/ending service as an AmeriCorps State and National, VISTA, or NCCC member.
A change may also be possible if you gained membership in a federally recognized tribe or status as an Alaska Native Claims Settlement Act (ANCSA) Corporation shareholder.
There are also other less usual situations, including those who may have been affected by a natural disaster and lived in a county that is eligible to apply for “individual assistance” or “public assistance” by the Federal Emergency Management Agency (FEMA).
You Might Need to Stay Within Your Metal Category
Beginning in 2019, those with a qualifying life event who are eligible for a Special Enrollment Period may be limited to a new plan within the same plan category as their current policy.
For example, if your current metal category is bronze, you might only be able to move into a bronze plan with another provider.
Or if you’re currently platinum, you might have to stay platinum, as opposed to moving down to a cheaper metal category.
This is ostensibly the case to make it more difficult for individuals to game the system if they know they’re going to start using their health insurance more frequently (or less).
So if you want to choose a different metal category, like moving from bronze to gold, or from platinum to silver, you might have to wait until the next Open Enrollment Period.
You can determine if you qualify for changes outside the yearly Open Enrollment Period via the Healthcare.gov website.
(photo: Marco Verch)