Insights: A qualifying life event usually requires you to make changes to your health insurance coverage.
You can only sign up or make changes to your health insurance coverage during certain times, but there is an exception and it’s called qualifying life events.
People choose a health plan or make changes to health coverage during open enrollment, which is usually in the fall or winter for employer health insurance plans. If you buy your own health insurance at Healthcare.gov, you can choose a plan from Nov. 1 to Dec. 15. Fourteen states and the District of Columbia have longer Affordable Care Act (ACA) health insurance marketplace open enrollment.
However, you may be able to change your health insurance in the middle of the year if you experience certain life events. Getting married, moving to a different state or having a baby are all qualifying life events that start a special enrollment period. During a special enrollment period, you can change your health coverage depending on the life event.
Here’s more about when you may be eligible to make coverage changes outside of open enrollment, what you can do, and advice to make the most of your health insurance options.
- Changes to your household, residence or loss of health coverage can launch a special enrollment period.
- Your health insurance plan may limit changes made during special enrollment only to issues directly related to the qualifying life event.
- The health insurance marketplace special enrollment is 60 days. Employers’ special enrollment periods are often between 30 and 60 days.
- You likely need to show documentation to confirm the qualifying life event, such as a marriage license or death certificate.
What is a qualifying life event?
Qualifying life events are life-changing events in your household, residence or other health insurance coverage that make you eligible to change your coverage outside of open enrollment.
The rules are slightly different for employer plans than they are for coverage you buy on your own at Healthcare.gov or your state health insurance marketplace.
“There are a number of different ways to configure your coverage as your life changes,” says Alan Silver, senior director and actuary, health and benefits, for Willis Towers Watson, a benefits consulting firm. “Every time you qualify for a life event, you should do a full review of what benefits are available to you and ensure that you’re maximizing your benefits for the lowest cost possible.”
How a qualifying life event works
If you experience a qualifying life event, you’re eligible for a special enrollment period to buy health insurance or make changes to your coverage outside of the annual open enrollment period.
You usually have 60 days from the qualifying life event (such as marriage) to make the change. The timeframe can vary based on the event and the type of coverage. Also, some deadlines have been extended because of the COVID-19 emergency.
Employer plans, however, may limit the types of changes you can make when you have a qualifying life event.
“Employers don’t have to allow for a full special enrollment where all benefit options that were available at open enrollment are back on the table — most employers don’t,” says Silver. “They only allow for changes in the coverages you’ve already selected.”
For example, if you have a baby, the employer may give you the option to add your child to your existing coverage or drop your coverage altogether and enroll somewhere else, he says.
Types of qualifying events
You can qualify for a special enrollment period at Healthcare.gov if you experience these qualifying life events. Here are examples of qualifying life events:
Changes in household
These events include if you or anyone in your household got married, had a child, adopted a child, placed a child in foster care, got divorced or legally separated and lost health insurance, or died and you lost coverage.
Changes in residence
These life-altering events include if you move to a new home in a new zip code or county; move to the U.S. from a foreign country or U.S. territory; if you’re a student who moves to or from the place you attend school; a seasonal worker moving to or from the place you both live and work; or you move to or from a shelter or other transitional housing.
You must prove that you had qualifying health coverage for one or more days during the 60 days before your move.
Loss of health coverage
Losing coverage and losing eligibility may include if you no longer have access to health coverage through a job or an insurance policy you bought on your own, you become ineligible for Medicare, Medicaid, or the Children’s Health Insurance Program (CHIP) or you lose coverage through a family member. For example, children turning 26 and can no longer be covered by your parent’s health plan or if your spouse loses a job and you no longer have health coverage.
There are also other situations in which you may qualify for a special enrollment period — see Healthcare.gov’s Special enrollment periods for complex issues page for more information.
The qualifying life events may be slightly different for employer coverage.
Who is eligible for qualifying life events?
You’re eligible for a special enrollment period if you experience the life event, and your family members may also be eligible if your life event affected their coverage. For instance, if you change jobs and your spouse and children lose health care coverage, they may qualify for a special enrollment period.
What kind of documents do you need for qualifying life events?
You generally need to provide proof of the qualifying life event, such as:
- A marriage license
- Adoption papers
- Utility bills or a lease or mortgage documents if you move
- A letter from your employer or insurance company if you lost coverage
See the Marketplace documents list at Healthcare.gov for details and deadlines.
The required documents can vary if you have employer coverage.
“Many require some form of documentation for a new dependent (a birth certificate or an official documentation of a marriage, for example), but some employers just require an affidavit,” says Silver.
He adds that many employers recently started asking for more documentation to make sure they’re only covering eligible dependents.
Advice if you qualify for a special enrollment period
If you have new choices — after you get married, for example — compare all of your options when deciding which coverage is best for you, especially if both spouses work and have health insurance through each of their employers.
“Look at everything — the plan designs of each member of the family, the costs out of their paycheck for each individual scenario, how often the participants use coverage, what kind of prescription drugs they use,” says Silver.
Silver adds that you may want to look for the lowest cost alternative for you. It may mean going with separate single coverage rather than a couple or family plan.
“That may mean everyone on the same plan, but very often for two people working full-time, it might mean each spouse enrolling separately, with a separate conversation around the merits of which plan is right for the children,” Silver says.
What if you don’t have a qualifying life event?
If you don’t have a qualifying life event, you usually must wait until the next open enrollment period to change your coverage. However, you can drop marketplace coverage at any time.
If you qualify for free or low-cost coverage through Medicaid or the Children’s Health Insurance Program, you can enroll in those programs at any time. The income requirements and other eligibility criteria can vary by state.
List of qualifying events for health insurance
Qualifying events are usually connected to moving, losing health coverage, or needing to add or remove someone from your health plan.
Qualifying life events that create a special enrollment period include:
- Birth or adoption
- Death of a spouse or dependent
- Job loss
- Job change
- Work hours reduction
Your state may offer additional rules for life events that create a special enrollment period.
Frequently Asked Questions
Do you need a qualifying life event to cancel health insurance?
Whether you can cancel health insurance outside of open enrollment varies by plan.
You usually need to experience a qualifying life event to cancel employer coverage.
However, if you bought your own health insurance at Healthcare.gov or from your state insurance marketplace, you can cancel that coverage at any time and either have the termination take effect right away or on a day you specify (such as if you know when new coverage will start).
Is Medicare eligibility a qualifying event?
Becoming eligible for Medicare isn’t specifically a qualifying event, but you can drop the coverage you buy on your own from Healthcare.gov or your state insurance marketplace at any time.
Medicare generally becomes your primary coverage when you turn 65 (unless you have health insurance from your employer or your spouse’s employer with 20 or more employees). So, you usually want to sign up during your initial enrollment period. That period runs from three months before to three months after the month you turn age 65.
You aren’t required to drop marketplace coverage at that point, but most people do so because you’ll no longer receive a subsidy to help pay premiums after you enroll in Medicare.
If you have coverage from an employer with 20 or more employees, that coverage pays first and Medicare is secondary. You may want to delay signing up for Medicare while you’re still working. If your employer has fewer than 20 employees, however, Medicare becomes your primary coverage at 65. You can keep your employer coverage, too, to supplement Medicare.
Is open enrollment a qualifying event?
No, open enrollment isn’t a qualifying event for a special enrollment period. Instead, open enrollment is the standard time of year when you can make changes to your health coverage.
You can sign up or switch health plans during open enrollment every year, which is usually in the fall or winter for employer plans. Open enrollment in the health insurance marketplace runs from Nov. 1 to Dec. 15 in most states.
You don’t need to have a qualifying life event to switch plans during open enrollment.
Is a spouse changing jobs a qualifying life event?
Yes, a spouse changing employers is usually considered a qualifying life event.
If your spouse loses health insurance when changing jobs and you were covered as a dependent on that plan, losing that coverage is a qualifying life event that makes you eligible to get coverage at Healthcare.gov or your state health insurance marketplace. Or you may be eligible to get coverage through your spouse’s new job.
Is divorce a qualifying event for health insurance?
Yes, divorce is considered a qualifying life event.
You can qualify for a special enrollment period if you get divorced or legally separated and lose your health insurance.
Is marriage a qualifying event for health insurance?
Yes, marriage is typically considered a qualifying life event.
You generally have up to 60 days from the date of your marriage to qualify for a special enrollment period on Healthcare.gov or your state marketplace.
You can usually add your spouse to your employer coverage or switch to that spouse’s coverage if his or her plan covers dependents.