What is a qualifying life event?

A qualifying life event (QLE) makes you eligible for a special enrollment period (SEP).

It’s an event that may trigger a need for health insurance or to make changes to your health plan, says Christian Worstell, a licensed health insurance agent with MedicareAdvantage.com.

Essentially, experiencing a life-changing event means you don’t have to wait until the annual open enrollment period to get coverage.

Here are a few tips to benefit most from the open enrollment period.

How a qualifying life event special enrollment period works

When you experience a qualifying life event such as the death of a spouse, birth or adoption, or moving to a different state, a special enrollment period opens for you. During special enrollment, a person can get health insurance or change coverage.

A qualifying life event can trigger a special enrollment period at any point during the year.

For an ACA marketplace plan, you can purchase a new policy or make changes to your existing policy 60 days before your qualifying life event -- or 60 days after. You have to wait until the annual open enrollment period to buy or modify coverage if your deadline passes.

Two ways to get health insurance during the special enrollment period are through either your state's insurance marketplace or the federal HealthCare.gov site. You'll submit an application with your personal information and check off which qualifying life event you have experienced.

After you complete the application, the site offers your health insurance plan options. You can choose a policy with your preferred coverage limit and deductible, and in most cases, you can buy a policy online.

Employer-provided health plans also have special enrollment periods when you have a qualifying life event. Check with your employer to find out how it handles special enrollment periods.

What qualifies as a life-changing event for insurance?

Many types of qualifying life events can make you eligible for a special enrollment period. Here’s a list of qualifying events for health insurance:

  • Losing coverage through your employer
  • Ending COBRA coverage
  • Gaining a dependent
  • Getting married or divorced
  • Loss of a family member
  • Having a baby
  • Adopting a child
  • Moving to a new state (including college students)
  • Becoming a U.S. citizen
  • Getting out of prison
  • Turning 26 while insured on a parent's policy

Who is eligible for a qualifying life event enrollment period?

Anyone over the age of 26 is eligible for a qualifying life event special enrollment period. You don't need to have an existing insurance policy to qualify.

For example, a 28-year-old woman who is uninsured would be allowed to purchase health insurance during a special enrollment period if she recently had a baby. Similarly, a 55-year-old would be allowed to adjust coverage during the SEP if their child turned 26 and was no longer eligible to stay on their plan.

What kind of documents do you need for a qualifying life event?

If you want to purchase health insurance during the special enrollment period, you need to show proof of the qualifying life event. In most cases, you have 30 days to show this documentation before your policy can be approved and your coverage takes effect.

The documentation required depends on the type of qualifying life event. For instance, if you recently had a baby, the child's birth certificate would serve as sufficient proof. If you lost coverage through your employer, you might submit a letter of termination from your old health insurance provider. If you move to a new state, a utility bill with your name and address or a signed lease agreement would work.

What if you don't have a qualifying life event and need health insurance?

You still have a few options if you need health insurance outside of the annual open enrollment period but haven't experienced a qualifying life event.

The first option is to consider enrolling in a Medicaid plan if you meet the income requirements. Medicaid is a federally-funded health insurance program that’s reserved for low-income families. There's no open enrollment period for Medicaid, so you can purchase coverage at any time.

A similar program with no open enrollment period is the Children's Health Insurance Program (CHIP). It can help you get affordable coverage outside of open enrollment if you have kids. Some state CHIP programs are rolled into Medicaid, while others are separate programs.

If you don’t qualify for Medicaid or CHIP, another option is to purchase short-term health insurance. These policies can be purchased in most states directly from private health insurance companies at any point during the year, without a qualifying life event.

These low-cost plans have limited benefits, so it’s wise to only keep short-term health insurance until you’re eligible for a health plan with comprehensive coverage, such as an ACA or employer plan.

Can I drop my health insurance without a qualifying event?

You're allowed to cancel an individual health insurance policy at any point during the year, even if you didn't experience a qualifying life event. However, you must have experienced a qualifying life event to cancel group health insurance through your employer -- unless you leave the job.

What is an open enrollment period?

The open enrollment period is a specific time when consumers can purchase a new individual health insurance policy or make changes to their existing policy. Open enrollment typically happens between November 1 and January 15 for ACA marketplace plans.

There are a handful of states that have longer ACA open enrollment.

Most pre-retirement members get their health insurance through an employer’s group plan. Open enrollment for those group health insurance plans varies by employer. Check with your company if you don’t know when it holds open enrollment.

Know more about the Open enrollment period for 2024.

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COBRA

The Consolidated Omnibus Reconciliation Act, better known as COBRA, allows you to stay on your former employer's health insurance plan to bridge the gap until you get new coverage. COBRA is expensive, as you will pay the full premium without help from your employer. It should be considered a short-term solution.
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Most people over the age of 65 qualify for Medicare. Original Medicare includes Parts A and B, for medical and hospital care. Medicare Advantage plans, administered by private health insurers, are called Part C, and include everything in Parts A and B. Many Advantage plans also include extra benefits like vision, hearing and dental coverage. Medicare Part D, which covers prescription drugs, can be added to either option.
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You may qualify for Medicaid based on your income. Guidelines for eligibility differ by state. To find out if you qualify in your state, contact the local Medicaid office.
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You can stay on your parent's health insurance plan until age 26 under the Affordable Care Act. For most people, this is the cheapest option. A dependent usually costs less to insure than a spouse or an individual.
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Health insurance through your employer is generally the most affordable option since employers pay a large portion of the monthly premium. If an employer-sponsored plan is available, it's likely the best choice. You may have more than one plan option to choose from.
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Preferred-provider organization (PPOs) plans are the most common type of employer-based health plan. PPOs have higher premiums than HMOs and HDHPs, but those added costs offer you flexibility. A PPO allows you to get care anywhere and without primary care provider referrals. You may have to pay more to get out-of-network care, but a PPO will pick up a portion of the costs.
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Health maintenance organization (HMO)

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Health maintenance organization (HMO) plans have lower premiums than PPOs. However, HMOs have more restrictions. HMOs don't allow you to get care outside of your provider network. If you get out-of-network care, you'll likely have to pay for all of it. HMOs also require you to get primary care provider referrals to see specialists.
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High-deductible health plans (HDHPs)

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High-deductible health plans (HDHPs) have become more common as employers look to reduce their health costs. HDHPs have lower premiums than PPOs and HMOs, but much higher deductibles. A deductible is what you have to pay for health care services before your health plan chips in money. Once you reach your deductible, the health plan pays a portion and you pay your share, which is called coinsurance.
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Exclusive provider organization (EPO)

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Exclusive provider organization (EPO) plans offer the flexibility of a PPO with the restricted network found in an HMO. EPOs don't require that members get a referral to see a specialist. In that way, it's similar to a PPO. However, an EPO requires in-network care, which is like an HMO.
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Silver plans provide a good balance of monthly premiums with out-of-pocket costs. Coinsurance is 70% with a silver plan, meaning you will pay 30% of the costs after your deductible is met, up to the out-of-pocket limit. Silver plans are a good choice for people who are in generally good health but don't want high out-of-pocket costs if something goes wrong.

Bronze plans are a popular choice with those who value low monthly premiums and are willing to pay more when they need care. Coinsurance is set at 60%, meaning you will pay 40% if you do need care, up to the out-of-pocket limit. Bronze plans are good for those who don't expect to need many services outside of preventative care throughout the year.

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The Affordable Care Act created insurance exchanges that allow people to compare plans. The health law also requires insurers to accept everyone and not charge them exorbitant rates. People who make below 400% of the federal poverty level qualify for subsidies to help pay for an ACA plan.
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ACA platinum plans have the highest monthly premiums, but the lowest out-of-pocket costs. You'll pay more monthly in return for lower deductibles, copays and coinsurance amounts. Coinsurance with platinum plans is 90%, which means you pay 10% after the deductible, up to your out-of-pocket limit. Platinum plans are good for those who anticipate a lot of medical needs throughout the year.

Gold plans cost a little less than platinum plans, and come with higher out-of-pocket costs. The coinsurance amount on a gold plan is 80%, which means you pay 20% after the deductible, up to your out-of-pocket limit. A gold plan is a good idea if you think you'll need a lot of care throughout the year, but don't want to pay platinum premiums.

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Frequently Asked Questions

Is Medicare eligibility a qualifying event?

Becoming eligible for Medicare isn’t considered a qualifying life event. However, assuming you have private health insurance coverage, you can drop your individual health insurance policy when you become eligible and enroll in Medicare.

You can get Medicare starting three months before your 65th birthday and ending three months after you turn 65.

Is a spouse getting a job a qualifying life event?

A spouse getting a new job counts as a qualifying life event because they lose their previous group coverage. In this case, they're able to enroll in their new employer's group health insurance plan within 30 days of their start date.

Is getting a new job a qualifying life event?

Getting a new job is not considered a qualifying life event. However, if you lose your existing job-based health insurance plan is considered a qualifying life event.

Is divorce a qualifying event for health insurance?

Yes, divorce is a qualifying life event for health insurance. You would be able to purchase your own individual policy through a SEP. However, you must have a divorce decree or proof of legal separation to take advantage of the SEP.

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