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What Is a Qualifying Event for Health Insurance?

Alvin Nelson
August 18, 2021
Alvin Nelson

What Is a Qualifying Event for Health Insurance?

According to the National Health Interview Survey (NHIS), 30 million citizens in the United States did not have life insurance during the first half of 2020. Those who lack insurance are likely to be young adults, have low incomes, or be Latino or Black. They may also live in states that do not offer expanded Medicaid.

Trying to select affordable health care insurance that meets the needs of your family is difficult. You must choose carefully because changes cannot be made outside the open enrollment period. The only exception is if you have a qualifying event for health insurance.

What is a qualifying event? Keep reading to find out everything you need to know about health insurance plans for families and when you can make changes outside the open enrollment period.

What Is Open Enrollment?

Open enrollment is the only time the year you are allowed to enroll, cancel, or make changes to your health, dental, and vision insurance for the upcoming year. You must make sure your existing insurance isn’t making any changes to your policy that affect your coverage. You must then compare your current coverage and cost with what is being offered through alternative plans or carriers.

Private companies are able to schedule their own open enrollment periods, usually in the fall. In addition to private company schedules, there is a national open enrollment period each year. For some states, this begins as early as mid-October and for others ends as late as the 31st of January.

The national open enrollment period for 2021 ran from November 1, 2020, to December 15, 2020. Because of the pandemic, the government declared a special enrollment period and re-opened enrollment for the Affordable Care Act (ACA) marketplace to run through August 15, 2021.

For the insurance year 2022, the ACA open enrollment is from November 1, 2021, to December 15, 2021. The Biden administration may extend it beyond that date.

The only exception to open enrollment is if you experience a qualifying event. If you meet the criteria for one of these special circumstances you will be able to make changes to your insurance outside the open enrollment period.

What Is a Qualifying Event for Health Insurance?

If you miss the open enrollment period or met open enrollment but experience a qualifying event that requires a change in coverage, you will be able to make changes under these qualifying events:

Loss of Health Care Coverage

You may lose your existing health care coverage due to loss of employment. Your employer may also stop offering coverage. 

This can also happen if your share of your employer's healthcare premiums no longer meets federal standards. If you are under COBRA you may exhaust the eligible time period.

In these instances, you will likely need a letter from your employer or HR department explaining the change in your health insurance arrangement or employer contributions. Other reasons include receiving insurance through your spouse, who lost that coverage, or you lose eligibility for Medicaid, Medicare, or CHIP.

People also lose health care coverage through their parent’s health plans when they reach age 26. Young adults are able to join or stay on their parent’s plans even if they are attending school, not financially dependent on their parents, or eligible to enroll in their employer’s healthcare plan. They can even remain on a parent’s plan if married or not living with their parents.

The young adult loses coverage under their parent’s healthcare on their 26th birthday. This is a qualifying event and they are granted a special enrollment period.

Changes in Household

Events taking place during the year may impact health insurance plans for family needs. If you have health insurance and get married, you can add your spouse to your policy. If you have health insurance and your spouse dies or you become divorced, you may remove your spouse from coverage.

If you or your spouse give birth or adopt a child, they can be added to your insurance. To be eligible for this special qualifying period you must enroll the child within 30 days of their birth, adoption, or placement for adoption.

HIPAA prohibits the use of preexisting condition exclusions for pregnancy, newborns, adopted children, or children placed for adoption. This only applies when they are enrolled within 30 days of birth, adoption, or placement. 

For events such as marriages, births, and adoptions you may need to provide documentation verifying your claim, including:

  • Copy of marriage license
  • Copy of child’s birth certificate
  • Copy of adoption confirmation documents
  • Copy of foster care confirmation documents

The foster care documents will specify that the child's placement with you is for adoption.

Becoming a U.S. Citizen

Green Card holders who are living in the United States as a visitor are not eligible for insurance. Once you become a U.S. Citizen you qualify for insurance under the Affordable Care Act (Obamacare). You have 60 days to enroll in a healthcare plan following the date of naturalization.

Three are numerous documents you may need to bring with you to confirm your legal immigration or citizenship status. This includes a Permanent Resident Card, Immigrant Visa, Employment Authorization card, Refugee Travel documents, Notice of Action, and more.

Release From Incarceration

When it comes to healthcare coverage, incarceration only applies to persons being retained in jail or prison. It does not include those who are on home confinement, probation, or parole. You do not qualify as incarcerated if you are in jail pending a hearing or trial and do not have a conviction.

You are unable to purchase health insurance during incarceration. Once released you have 60 days to apply for coverage under the special qualifying period. If you miss applying within that period you will need to wait until the next standard open enrollment.

Leaving AmeriCorps

Members of the AmeriCorps receive health care coverage at no cost under the AmeriCorps Health Benefits Plan. This is available to members within 24 hours of enrollment into the plan and terminates automatically on the day service ends. This plan provides coverage for major medical and surgical costs, prescription drugs, and hospitalizations.

Permanent Residential Change

When you move to a new area that is outside the area of your current insurer’s coverage you have a qualifying event to obtain health insurance outside the open enrollment period. You will likely need to furnish evidence of this change. This includes items such as a utility bill from your previous address and one from your current address.

Is It Cheaper to Buy Health Insurance Online?

You may be wondering whether health insurance online vs agent is the better choice. Whether trying to review your standing policy during the open enrollment period, or make changes due to a qualifying event for health insurance, you need to do a comparison of several providers and policies.

The best way to obtain a comparison of price and carriers is to request a comparison from Healthplans.com. You can check out the Obamacare plans available, then use our website to request a price comparison. Request your comparison today so you are ready when your open enrollment period arrives.

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Advertised Pricing:

There are several factors that impact your monthly premium; including your age, geographical location, annual income, dependents, and the type of plan you choose. Monthly premiums do not include out-of-pocket costs.

The advertised price may not be typical. It was generated using the Kaiser Family Foundation's subsidy calculator that was accessed on September 16, 2020. The following parameters were used: 21 year old adult, non-tobacco user, annual income of $24,700 in 2020, no children, and no available coverage through a spouse's employer. The resulting monthly premium was $30 per month (or $360 per year after $2,751 in subsidies) for a Bronze Plan. Even when using the same parameters, the resulting premium and subsidy calculations may be subject to change.