Qualifying Life Events for a Special Enrollment Period

(Major Medical Insurance)
Jenifer Dorsey
February 26th, 2020 April 18th, 2019 |
Read time: 4 minutes

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Sometimes, life happens and you wind up uninsured or enrolled in health insurance that’s no longer the best fit.

Fortunately, if you experience what the Affordable Care Act (ACA), also known as Obamacare, considers a qualifying life event, you may be eligible for a special enrollment period.

What is special enrollment?

Special enrollment is a set amount of time (typically up to 60 days) in which you may enroll in an Obamacare health insurance plan or switch plans outside of the annual open enrollment period.[1]

What are qualifying life events?

You’ve recently had a baby or adopted. You lose access to your employer-sponsored health insurance. You move out of your current plan’s coverage area to pursue a new opportunity. These are all examples of possible qualifying life events that could make you eligible for a special enrollment period.

More specifically, HealthCare.gov includes the following qualifying life events:[2]

  • Loss of health coverage – This includes losing your current job-based, individual and student plans; eligibility for Medicare, Medicaid or CHIP; and turning 26 and aging out of a parent’s plan.
  • Kids – This includes adding to your household by having a baby or adopting, or having a child removed from your household and placed in foster care.
  • Marriage/Relationship status – This includes getting married, divorced or legally separated from your spouse, however, if divorce or legal separation does not result in a loss of coverage you won’t be eligible for special enrollment.
  • Death – The death of a household member that’s on your policy may qualify you for special enrollment if it results in losing eligibility for the plan you’re currently enrolled in.
  • Changes in residence – This includes moving to a new ZIP code or county, students moving to or from the place they attend school, seasonal workers moving to or from the place they both live and work, and moving to or from a shelter or other transitional housing.
  • Other qualifying events – This includes income changes that affect the coverage for which you qualify, gaining membership in a federally recognized tribe or status as an Alaska Native Claims Settlement Act (ANCSA) Corporation shareholder, becoming a U.S. citizen, leaving jail or prison, or AmeriCorps members starting or ending their service.

These are the most common ways to qualify for a special enrollment period; however, there may be other situations in which you could become eligible. Find out if you qualify for a special enrollment period.

To determine whether or not you qualify for special enrollment, you will want to work with a health insurance agent or contact your state’s ACA exchange. You may be required to provide documentation for your qualifying life event.

Find your state’s health insurance exchange.

How long does a special enrollment period last?

Special enrollment periods typically last up to 60 days after a qualifying life event.[3] To find out if you qualify for a special enrollment period and for what duration:

  • Visit HealthCare.gov and answer a few questions. This screening tool will help you determine whether or not you may be eligible and point you toward the correct state-based or federally facilitated exchange from which to begin the application process.
  • Contact your state-based or federally facilitated exchange. Find your exchange.

What if I don’t want to buy health insurance from an exchange?

Special enrollment is not limited to state-based and federally facilitated health insurance exchanges. If you qualify for special enrollment, you may also purchase qualified health insurance plans in the private marketplace.

Keep in mind that premium tax credits and cost-sharing reductions may only be applied to health insurance plans purchased through state-based and federally facilitated exchanges.

Estimate your subsidy now

Are there other options if you don’t qualify for special enrollment?

If it’s outside of open enrollment and you don’t qualify for a special enrollment period, you may have other health insurance options that are available year-round. Three possibilities include:

Medicaid is an insurance program that provides free or low-cost healthcare coverage to those who meet eligibility criteria. Get info on your state’s program at Medicaid.gov.

Medicaid is considered minimum essential coverage under the Affordable Care Act and includes comprehensive benefits similar to individual major medical insurance. Again, you must meet your state’s eligibility requirements to enroll in Medicaid.

Short term health insurance provides temporary benefits for unexpected medical expenses resulting from injury or illness. Policies last as few as 30 days (and up to 364 in some states).

Short term health insurance is not guaranteed issue. If you qualify, you may begin coverage as soon as the day after your application is approved. Short term health insurance is not minimum essential coverage, meaning these plans are not ACA-compliant, do not include all of the essential health benefits and you may be denied coverage based on your health history.

However, with fewer benefits than ACA-compliant health insurance, these options often have lower monthly premiums than unsubsidized ACA-compliant policies.

Learn about short term health insurance.

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Summary + next steps

If you have a qualifying life event, you may be able to enroll in health insurance or switch health insurance policies outside of open enrollment. If you’re not eligible for special enrollment, you may be able to find coverage through an alternative option such as Medicaid or short-term health insurance which are both available year-round if you qualify.

Speak to a licensed agent at 888-855-6837.

Visit HealthCare.gov to see if you:

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Originally Published On September 9th, 2015
Independence American Insurance Company and/or Madison National Life Insurance Company, Inc. may underwrite the products referenced on this website. Legal Disclaimers.