Change is a part of life. Sometimes, those changes can impact your health insurance coverage. A qualifying life event for insurance is the name for a change in circumstances that enables a person to modify or enroll in a new health plan outside of the open enrollment period. Instead, they sign up during a special enrollment period (SEP).
A number of events qualify for this designation, including but not limited to the loss of a job, marriage, divorce, welcoming a new child to the family and a change in residence. In this article, we’ll address some common questions about this topic, such as: what are qualifying life events for medical insurance? Is the time allotted for a qualifying life event 30 or 60 days? What events don’t count as QLEs? In addition, we’ll share some insights on what to do if you qualify for a special enrollment period, and offer some options in case you don’t qualify.
After reading this guide, you’ll better understand what changes in your life will allow you to sign up for a new health insurance policy outside of the standard enrollment period.
Main Takeaways
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A qualifying life event (QLE) is a change that is significant enough it enables a person to modify their health coverage or sign up for a new health plan at a time other than open enrollment.
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During that special enrollment period (SEP), the person will need to show documentation that verifies the change and, in some cases, confirms their recent loss of coverage.
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Not all life changes will be eligible for an SEP. It’s important to know which ones qualify, which ones don’t and what steps to take, in either scenario.
Common Qualifying Life Events for Insurance
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Qualifying Life Events for Insurance (QLEs) |
Not Qualifying Life Events for Insurance (Non-QLEs) |
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Getting married |
A desire to change health plans |
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Getting divorced or legally separated |
Failure to pay your premium |
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Having a baby/adopting a child |
Becoming pregnant (in most states) |
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Losing a job/COBRA termination |
A temporary move |
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A permanent move |
Missing the open enrollment period |
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New, eligible immigration status |
Dissatisfaction with in-network providers or facilities |
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Release from jail or prison |
Dissatisfaction with your health plan provider |
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Turning 26 |
Expiration of a short-term policy |
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Loss of other health coverage, such as Medicaid or CHIP |
Voluntarily dropping health coverage |
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Death that causes a loss of insurance in the household |
Losing coverage because you provided false information |
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Turning 65 |
A divorce that does not result in losing health care coverage |
What is a Qualifying Life Event for Medical Insurance? Here Are Some Categories
Qualifying life events for insurance can run the gamut, and some are more common than others. The list below explains a few of the common categories, followed by some of the documentation you may want to have at the ready when applying for a SEP. You can also explore more information using the “Do You Qualify” eligibility checker here.
Loss of health coverage
If you or someone in your household loses your health care coverage for reasons beyond your control (i.e. not because you stopped paying your premium and let your policy lapse), you may qualify for a special enrollment period.
This may apply to people who:
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Lose a job
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Reach the end of their COBRA coverage/wish to terminate COBRA
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Are no longer eligible for other health coverage, such as Medicaid or CHIP
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Turn 26 and age off their parents’ plan
Documentation that might be helpful:
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Paperwork indicating that your coverage has ended and the date it ended.
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A letter from your former employer, if applicable, stating that your job has been terminated or your coverage has been terminated.
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Your notice of eligibility for COBRA or a document stating the date for termination of COBRA.
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For those turning 26, notifications that you’ve reached the maximum age to be on your parents policy, or a document showing the last day of coverage on that policy.
Household changes
If you or others in your home rely on the coverage of a family member and circumstances within the home change, you may qualify for a SEP. QLEs related to changes in the household may apply to people who:
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Get married
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Get divorced or legally separated (and lose their health insurance)
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Have a baby or adopt a child
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Lose health coverage because the primary policy holder dies
Documents that might be helpful:
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Marriage certificate
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Court-issued decree of separation or divorce that shows loss of coverage
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Birth certificate or proof of adoption
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In the case of death, a document showing the last day of coverage
Change in residence
If your place of residence changes, it could impact your eligibility for the health plan you originally signed up for. If you’re able to prove that you had health coverage for 60 days prior to the move, you may qualify for a SEP. QLEs related to change in residence may apply to people who:
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Move to a new home in a different zip code or county
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Move to the United States from a foreign country or U.S. territory
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Move to attend school
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Move due to being a seasonal worker
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Leave or enter a shelter or transitional housing
Documents that might be helpful:
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Proof of residency, such as a driver’s license or state ID with the new address; a mortgage document or rental agreement; a utility bill; vehicle registration. It may depend on where you moved, but typically you’ll need the documents to be dated 30 to 60 days from the QLE.
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For students, documentation from the school.
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If you’re unhoused you may be able to submit a reference letter from someone who can attest to where you’re living.
Other qualifying life events
A number of other life changes could make you eligible for a SEP. Just a few additional examples include:
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Turning 65 and becoming eligible for Medicare
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A change in immigration status, such as becoming a U.S. citizen
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Leaving jail or prison
Documents that might be helpful:
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If you’re turning 65, an official government document that shows your birth date, such as a birth certificate or social security card
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If you’re a new U.S. citizen, your naturalization certificate
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If you’re leaving jail or prison, your release orders
It’s important to note that this is not an exhaustive list. If you have experienced exceptional circumstances that impact your access to health insurance you may qualify for a special enrollment period. Later in this article, we’ll cover the steps to take to see if you might be eligible.
What’s Not a Qualifying Life Event
Just as it’s important to read up on the QLEs that will enable you to sign up for a new policy, it’s also helpful to know about the events that don’t qualify for a special enrollment period. We’ve explained some of those here:
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A desire to change health plans. If you sign up for a plan and then have buyer’s remorse, you can’t simply switch plans. You’ll have to wait until the next open enrollment period to pick a new plan, or go without coverage until then.
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Becoming pregnant. In most states, pregnancy is not considered a QLE, although there are some exceptions. The birth of the child, however, will be a QLE.
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Failure to pay your premium. If you don’t pay for your health plan, you risk losing coverage. You do not qualify for a special enrollment period.
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A temporary move. If you’re relocating for a short period of time, whether it’s for a vacation or for medical needs, that change is not considered a QLE.
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Missing the open enrollment deadline. If you didn’t sign up for a plan during the designated open enrollment period, you’ll need to wait until the next coverage year to start a plan.
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Dissatisfaction with your prescription drug coverage and access to providers. Different aspects of your health plan can change during the year, including what medications your policy covers and which providers and facilities are in your network. Those changes do not enable you to change plans, even if your medications or providers are impacted.
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A short-term policy expires. When a short-term policy expires it is not a QLE because the policy is not considered “minimum essential coverage.”
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Voluntarily dropping health coverage. If you decide to let your health insurance policy lapse you won’t be able to sign up for a new policy until open enrollment, barring any QLEs.
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Your insurance company dropped you for providing false or incomplete information. In the event that you gave incorrect information and lose your insurance because of it, you will not qualify for a SEP.
How to Report a Qualifying Life Event
Sometimes a life change is planned, other times it’s unexpected. With most qualifying life events, you have 60 days to make changes or sign up for a new policy (when signing up for Medicare you have 90 days before you turn 65 and 90 days after). Be sure and sign up sooner than later, so you don’t miss the window of opportunity.
If you have access to a group plan through an employer, check with your HR department to determine if you’re eligible for a SEP and see what’s available. Otherwise, you could visit healthcare.gov to inquire about a new policy, or visit the site of a state-run exchange or inquire with a health insurance provider directly about applying during a special enrollment period.
As you do, here is some information you may want to have handy:
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Documentation that confirms loss of health insurance coverage, whether it’s from your employer or your insurer.
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The date of your QLE.
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Paperwork that verifies your QLE, whether that’s a birth certificate, marriage certificate, death certificate, documents proving a new residence or other information. (See the above section for more details on documents that might be helpful).
If you are approved to sign up for a policy outside of open enrollment your plan should begin coverage the first month after your application was submitted.
Other Ways to Get Health Insurance Outside of Open Enrollment
If you learn that your particular change in circumstance isn’t considered a qualifying life event, and you find yourself without health insurance, you may still have options for coverage. Those include the following:
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Medicaid/CHIP. Depending on your income, you may qualify for health insurance through Medicaid or the Children’s Health Insurance Program (CHIP). If so, you can apply for those throughout the year.
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COBRA. If you’ve recently become unemployed, find out if you might be eligible for COBRA insurance through your former employer. Please note that individual members are not eligible for COBRA.
Learn More About Getting Health Insurance
Health insurance serves two important purposes: it can help you access care and it may help protect you from unexpected, high medical costs.
However, just as no one plans to get sick or injured, no one plans to lose their health insurance. Should a situation arise where you find yourself without coverage, it’s important to know what steps to take and act quickly. Now that you know the answer to the question “what are qualifying life events for insurance?” and you have a better understanding of SEPs and the ins and outs of getting insurance, you’re better equipped to make informed decisions for yourself and your family when life happens.
Want to learn more about insurance and how to be an active member? Check out the following articles and resources:
How Health Insurance Works: Feel Confident Using Your Coverage
How to Get Health Insurance if You Aren’t Covered
