Walsh Consultant

Trusted Health Consultant

Qualifying life events for Special Enrollment

Qualifying life events for Special Enrollment

Every year, Americans are allowed a specific window of time to change or enroll in individual and family private health insurance coverage for the following year. This is known as the Open Enrollment Period (OEP), which typically lasts from November to mid-January.

But what if you need to enroll in health insurance outside of that timeframe? You have options! Let’s walk through how a qualifying life event could make you eligible for a Special Enrollment Period and what kind of life changes qualify.

What is a Special Enrollment Period (SEP)?

A Special Enrollment Period (SEP) is a window of time when people can enroll in health insurance outside of the Open Enrollment Period. It is typically triggered by a qualifying life event (QLE). An SEP ensures that people going through specific life changes, especially ones that result in loss of health coverage, can enroll in a new health plan.

What is a qualifying life event?

A qualifying life event, sometimes referred to as a qualified status change, is a change in your current situation that makes you eligible for an SEP. But what does that mean? Think of it in terms of a big life event. If you experience something that affects your household size or involves a change in residence, income or your access to health insurance, you may be eligible.

How many days after a qualifying life event do you have to enroll in a health insurance plan?

In most situations, you have 60 days from the date of a qualifying life event to apply for health coverage. But this looks different from state to state. Depending on the situation, some states will allow you a 60-day window both before and after a qualifying life event to enroll in coverage.

Status changes: Marriage, divorce and legal separation

Getting married, divorced or legally separated are all considered qualifying life events. In each situation, the size of your household is changing, and coverage must be adjusted to reflect that change.

Marriage: For those getting married, you’ll be allowed a 60-day window from the date of marriage to change your coverage, including adding a spouse to your employer-sponsored health plan.

Divorce or legal separation: In the event of a divorce, the spouse who does not hold the policy may be able to purchase their own individual plan through an SEP if they have a divorce decree or proof of legal separation. However, this can get complicated depending on legal proceedings and state rules.

Is getting pregnant a qualifying life event?

Though this varies by state, in most cases, getting pregnant is not considered a qualifying life event. But don’t worry – if your prenatal care is provided in-network, your current insurance should cover it. It’s important to call your insurance provider and ask questions before your first prenatal appointment to see what your insurance will and will not cover.

What about giving birth or adopting?

Giving birth and adopting are both considered qualifying life events, as you are adding a new dependent to your health insurance and changing the size of your household. Typically, parents have 60 days from a baby’s delivery or a child’s adoption to enroll in coverage for their little one.

Is losing or getting a new job a qualifying life event?

Yes, if you lose your employer-sponsored health care, you’re eligible for a Special Enrollment Period. There’s no distinction between leaving your place of employment willingly, like in the case of resignation, or unwillingly, like with a layoff or firing.

Involuntary or voluntary loss of health insurance coverage

In most cases, an involuntary loss of health coverage, such as from divorce or the death of a family policy holder, makes you eligible for an SEP. But what about voluntary? And what’s considered “voluntary loss”?

You won’t qualify for a Special Enrollment Period if you voluntarily dropped your coverage. This includes losing your coverage because you didn’t pay your premiums or choosing to drop off a parent or guardian’s plan.

Is quitting your job an involuntary loss of health coverage?

Yes, leaving a job, no matter the situation, counts as an involuntary loss of health insurance. This might be surprising if you left your job voluntarily but think of it this way – while you may be choosing to leave your job, you’re not technically choosing to lose your health coverage.

Medicaid coverage ending

You may be eligible for an SEP if you are denied or lose Medicaid coverage due to income changes, a child in your household ages out of the Children’s Health Insurance Program (CHIP) or another qualifying circumstance occurs. To learn more, you can get in touch with your state’s Medicaid office.

Is a spouse quitting their job a qualifying event?

Yes. If your spouse quits their job, it’s considered an involuntary loss of health coverage, no matter the situation. If they were the one whose employment provided health insurance, you would be able to seek a new plan during a Special Enrollment Period. If your spouse leaves their job and you want to fold them into your health coverage, this will also trigger an SEP.

Is turning 26 a qualifying life event?

Turning 26 is a qualifying life event. This is when most dependents lose access to their parents’ health insurance coverage. Depending on where you live, you may have 60 days before your coverage ends and 60 days after to find a new plan during a Special Enrollment Period.

If there is a death in the family

If you share health coverage with a family member who passes away, it is a qualifying life event. Examples can include the loss of the primary holder of your family’s health insurance policy, the loss of a minor child and the loss of a family member whose income contributed to the insurance coverage.

If you’re moving out of coverage range

If you move out of your health plan’s coverage range, you may be eligible to enroll in a new plan during an SEP. According to HealthCare.gov, this may include moving to a new ZIP code, leaving a transitional housing situation, such as a shelter, or a student moving for school.

Have more questions about individual health insurance?

Our experts will help you find a health plan you’re confident in – no matter your situation.