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

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People who lose their employer-sponsored health insurance may qualify for a COBRA plan. COBRA lets you keep your former employer's health plan, but you're responsible for paying all of the costs, including your former employer's portion.
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Medicare

People who are 65 and over qualify for Medicare. You can choose Original Medicare (also called Parts A and B), which is offered by the federal government, or Medicare Advantage (also called Part C), which private insurers provide. The average annual premium for Original Medicare is about $1,600. Medicare Advantage's average yearly premium is $336, but you may have higher out-of-pocket costs than Original Medicare.
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Medicaid

Low-income Americans qualify for Medicaid. Thirty-eight states expanded Medicaid eligibility, so lower-middle-class Americans may also be eligible in those states. Medicaid offers comprehensive benefits, but at little to no cost depending on your income. Each state has its own eligibility. Some states are flexible with Medicaid eligibility for people who are pregnant, a parent or disabled. If your household income is below 138% of the federal poverty level, you're likely eligible for Medicaid if you live in a Medicaid expansion state. That level is $17,609 for an individual, $23,791 for a family of two, $29,974 for a family of three and $36,156 for a family of four. Non-Medicare expansion states have stricter income guidelines. Check with your state's Medicaid program to see if you qualify.
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Parent's employer-based health insurance

The Affordable Care Act lets children stay on a parent's health plan until the age of 26. Having a child on a parent's health plan may or may not increase premiums. It depends on whether you already have family coverage when adding the child to the plan. If a parent already has family coverage, adding a child won't likely increase premiums. However, going from single or couple to family coverage could cause premiums to skyrocket. The average single coverage employer-sponsored plan premium is $1,186. The average family plan is $5,447.
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Preferred-provider Organization (PPOs)

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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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Individual insurance/Affordable Care Act
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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Individual insurance/Affordable Care Act
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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Silver is the second most popular plan in the ACA exchanges, with 35% of people with a Silver plan. Silver has lower premiums than any plan except for Bronze. However, it has lower out-of-pocket costs than Bronze. Silver plans pick up 70% of the costs, while members pay 30% The average single coverage in a Silver plan is $481 monthly and $1,179 for a family plan.

Bronze is the most popular type of plan in the ACA exchanges, with 41% of members with a Bronze plan. These plans have the lowest premiums, but also the highest out-of-pocket costs in the exchanges. Bronze plans pick up 60% of the costs, while members pay 40%. The average single coverage monthly cost in a Bronze plan is $440 and $1,080 for a family plan.

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Individual insurance/Affordable Care Act
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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Platinum plans have the highest premiums but the lowest out-of-pocket costs. So, you pay more for the coverage initially but less than other plans when you need health care services. Platinum plans pick up 90% of the costs, while members pay 10%, Not many health insurers offer Platinum plans. Only 2% of members in ACA plans have a Platinum plan, so you may have trouble finding one. The average monthly premiums for single coverage in a Platinum plan is $706 and the average family coverage costs $1,460.

Gold plans have lower premiums than Platinum, but higher premiums than Silver and Bronze. Gold also has lower out-of-pocket costs than Silver and Bronze, but higher than Platinum. Gold plans pick up 80% of the costs, while members pay 20%. The average monthly premium for a single Gold plan is $596. Family coverage averages $1,426 per month.

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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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