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What is considered a qualifying event to change health insurance?

To sum it up...
  • The Open Enrollment Period is the time for buying qualified health insurance
  • Special enrollment is an exception to the rule against signups after open season
  • Qualifying events must support requests for Special Enrollment Periods (SEP)
  • The special enrollment is a sixty-day period from the date of the qualifying event
  • Qualifying events involve status changes requiring a new opportunity for enrollment

The federal and state rules permit signups for new insurance when status changes require it. These changes also called life events generate a sixty-day window to get new health insurance.

Qualifying events require new insurance because some important part of the individual’s status changes. For example, if one moves to a new location that is outside of the service area of the current health plan, the rules permit a new signup. The change in location is an important change in status. The current policy does not apply to the new location.

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The Individual Mandate

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The individual mandate is the reason the rules permit qualifying events and special enrollments. The Affordable Care Act requires that nearly everyone get and keep health insurance coverage. The qualifying events involve changes that cause someone to be uninsured.

The primary goal of the law is to get everyone covered with qualified health insurance. The law does not seek to impose the penalty, rather it seeks to promote universal health insurance coverage. The qualifying events carry out the purpose of the legislation. They recognize that normal occurrences cause a need to reopen the sign-up window.

The Open Enrollment Season

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The Obamacare open enrollment season varies from year to year but begins in November and runs through January of the next year.

For the calendar year 2017, the open enrollment period began on November 1, 2016, and runs through January 31, 2017. The open enrollment permits every qualified person to buy health insurance coverage that meets the individual mandate.

Exemption, Extension or Exception

Those that miss the deadline for Open Enrollment can still avoid the penalty. They can use an extension of the deadline, an exemption from the mandate, or an exception to open enrollment for status changes.

Exemptions avoid the penalty by showing it does not apply. Examples are a financial hardship, and lack of taxable income.

Extensions add days to the closing deadline for application. The federal government and the states have the power to extend the deadline. They have done so in the past to provide a fair opportunity for enrollment.

They have extended the deadline for storms, floods, and natural events that caused delays. It includes system crowding when technical problems interfere or the applicant rush to beat the deadlines drags the system.

Exceptions use qualifying events to get special enrollment periods. One must prove that the event occurred and the time that it occurred. These sixty-day extensions also can get Marketplace benefits such as advance tax credits for premiums and help with costs and out-of-pocket expenses.

Exceptions for Life Events

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The states and the federal government each recognize exceptions to the rule against sign-ups after the open enrollment period. The federal rules and the state governments recognize the below-listed items as qualifying events for a special enrollment period. The special enrollment period comes outside of the official enrollment periods.

Private insurance companies can issue policies that meet the standards of the Affordable Care Act. Unlike policies sold elsewhere, the SEP provides access to premium subsidies, costs reduction assistance, and other Marketplace financial assistance.

  • Adoption of a child
  • Marriage
  • Divorce
  • Childbirth
  • Moving to different coverage area
  • Loss of coverage as dependent on 26th birthday

Understanding Qualifying Events

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Qualifying events add a practical side to the Affordable Care Act. In a wide and diverse population, there must be a system to deal with the expected contingencies of living. Lives are dynamic and ever-changing situations.

Over the course of a one-year insurance cycle, millions of people will move, marry, divorce, have children or experience some other significant change in their status. Healthcare.gov breaks down the qualifying events into four useful categories.

The below-listed items offer a convenient way to understand qualifying events.

Loss of Health Coverage – This covers loss of coverage as an employee, dependent of an employee, and dependent of someone divorced, or legally separated. This category includes loss of Medicaid and or CHIP due to a rising income.

Changes in the Household – In addition to those above, this includes adoption of a child, and death in the family.

Change of Residence – Moving can interrupt coverage from an existing provider plan. Changes in residence include moving to a housing shelter, students moving to and from school, and seasonal workers that travel to get work.

Personal Changes – These status changes include release from incarceration, returning to the US from abroad, becoming a US citizen, membership in a recognized Amerind Tribe, and changes in income that create eligibility for Marketplace policies.

Appeals for Denied Requests

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If one applies for a special enrollment, then it can be granted or denied. If denied, then there is a right to appeal. The appeal requires a statement on the appeal form for the state of residence.

Applicants must send the appeals to the Marketplace, at the Appeals Division. There may be requests for additional information on the matters stated in the appeal. Appeals can provide a new opportunity to enroll and can include retroactive coverage to the earlier time if needed.

Complex Enrollment Situations

There are also a group of complex issues that the system recognizes. Many complex issues stem from errors in personnel performance or information provided to applicants.

The best advice is that if one believes they have an issue of fairness that interfered with their applications, then they should immediately report it to healthcare.gov and request relief.

Qualifying Events Help Get Coverage

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Qualifying events are the basis for getting a special Enrollment Period and for signing up for health insurance after open enrollment period has closed. They are practical events that commonly happen to thousands of people in the US, but they require a new opportunity to get health insurance coverage. Understanding qualifying events can help avoid the penalty for being uninsured.

Comparison shopping is the ideal solution for finding the best policy for a changed status. Comparison shopping can focus the search on the customer’s priorities.

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