What Is a Qualifying Life Event (QLE) for Health Insurance?

Millions May Qualify and Not Know About It, Are You One of Them?

Woman considering health insurance changes due to qualifying life event

 Henglein and Steets/Cultura/GettyImages

Every year during open enrollment Americans can shop for their health insurance. A lot of people don't know that you may also shop for health insurance outside of the open enrollment period if you have a Qualifying Life Event (QLE). Such events include marriage, having a child, and divorce. After one of these events, the individual may use the special enrollment periods (SEP) to sign up or change their health insurance plan.

In fact, the Robert Wood Johnson Urban Institute found that millions of Americans who are eligible for QLE special enrollment periods may be unaware. The policy research institute reported that according to the Centers for Medicare and Medicaid Services (CMS) under 15% or eligible individuals use the qualifying event to change or enroll in insurance plans. The study found that:

  • 12.9 million people could use SEPs to enroll
  • 20.6 million people could get temporary coverage for gaps

There are several different kinds of Qualifying Life Events for health insurance that may make you eligible for special enrollment in a health insurance plan. Here are the basics you need to know to find out if you may be eligible for a Qualifying Life Event or Special Enrollment Period and how it works.

What is a Qualifying Life Event (QLE)?

A Qualifying Life Event (QLE) is a major life change that may affect your health insurance needs and/or impacts your qualification for existing health insurance or subsidies. Qualifying life events may make you eligible for a special enrollment period to purchase health insurance in the marketplace outside the open enrollment period.

Examples of Qualifying Life Events For Health Insurance

There are several different kinds of qualifying life events, many of them revolve around changes in job, location, income, or family status. Here are just a few examples of common QLE's:

  • Change in family status, members of the household or household size. This could include getting married, getting separated, gaining a dependent, losing a family member, and court-ordered family dependent changes, among other things.
  • Change in where you live if it is a permanent move. This could including moving to a new State or moving when you are a student, for example.
  • Change in eligibility for Marketplace coverage or loss of a health plan eligibility (either 60 days in the past, or 60 days into the future of the QLE) read more about this in the special enrollment period explanation below.
  • Change in eligibility for help paying for coverage, nor change in your income level that would qualify you for different plans like Medicaid, or the denial of coverage through Medicaid or Children's Health Insurance Program (CHIP)
  • Errors in your enrollment plan, or other exceptional circumstances (read more about exceptional circumstances in the section below).

What Is a Special Enrollment Period (SEP)?

A Special Enrollment Period allows you to enroll in or change health insurance plans outside of the open enrollment period and is triggered by a qualifying life event.

The special enrollment period normally lasts 60 days from the date of the life qualifying event. This means that you normally have 60 days from the life change that qualifies you for enrollment to enroll.

Examples of Situations That May Not Be Considered Qualifying Life Events

The concept of a qualifying life event is that it is a life-changing circumstance that impacts your situation, in particular to health insurance. Although some of the qualifying life events seem straightforward, there are important factors about these qualifying life events that make them qualify you for special enrollment. If for example, you have a situation that seems to fit a qualifying life event, but it doesn't alter your health plan benefits or change your actual situation, it may not qualify. For example:

  • Divorce or loss of a family member, without any resulting change in coverage. For example, if you remain eligible for the same health benefits despite the loss or separation, then you may not qualify for the special enrollment period.
  • Moving for reasons like a vacation
  • Dropping current insurance coverage voluntarily
  • If your insurance was canceled for non-payment.

Do You Need to Prove Your Eligibility for a Special Enrollment Period?

You may be asked to prove your eligibility for a Special Enrollment Period. For example, if you are applying for special enrollment due to a denial of coverage by Medicaid or CHIP, you may be asked for proof. Another example may be if you gain a dependant via a court order.

If you are asked to prove eligibility, you may need to provide that proof within 30 days of the selection of your plan. You will receive notices regarding the status of your Special Enrollment Applications and requirements of proof to keep you updated on the status and requirements.

Exceptions or Special Circumstances for Qualifying Life Events to Qualify for Special Enrollment

There are special situations that fall outside the examples we outlined above that may still qualify you for a special enrollment period. These cases are termed "complex issues" and are reviewed on a case by case basis.

What If You Don't Qualify for Special Enrollment?

If you do not qualify for special enrollment because you did not have a qualifying life event, then you can look into applying for Medicaid or the Children's Health Insurance Program (CHIP).

If you do not qualify for those, you may also consider looking into membership health insurance or temporary health insurance. Temporary or short-term health insurance is not a good long-term option but may offer you a temporary solution to make sure you have health insurance while you wait for the next open enrollment period.