Speaking with Employees About Qualifying Life Events and Special Enrollment

The Affordable Care Act (ACA) and Medicare law outline certain qualifying life events (QLEs) that trigger a Special Enrollment Period.

Most people who don’t enroll in health care marketplace or Medicare coverage or update their existing coverage during the annual Open Enrollment Period won’t be eligible to do so until the next Open Enrollment Period arrives. However, the Affordable Care Act (ACA) and Medicare law outline certain qualifying life events (QLEs) that trigger a special, limited-time window during which individuals can make changes to their coverage. This window is called a Special Enrollment Period.

Qualifying life events tend to include things that most people would consider major life changes: getting married, getting divorced, having a baby, adopting a child, or moving to a new place, for example.

When talking with employees about Special Enrollment Periods, it’s important for them to understand that qualifying life events are strictly defined by the law. Unless your employee experiences one of these events, the Open Enrollment Period (or the annual enrollment period for your company-sponsored health insurance) is their only chance during each year to apply for or update insurance coverage. However, for those employees who do qualify, Special Enrollment Periods provide an important opportunity to update their coverage in response to significant changes in their lives.

Understanding Special Enrollment Periods

Unlike the annual Open Enrollment Period, a Special Enrollment Period isn’t a “one-size-fits-all” window — that is, it doesn’t depend on a predefined set of dates. Instead, a Special Enrollment Period begins on the date that the individual experiences a qualifying life event. If that individual fails to report their qualifying life event and/or misses their Special Enrollment Period, which usually lasts for 60 days, then they won’t be able to apply for new or updated coverage until the next Open Enrollment Period. Job-based plans are required to provide a Special Enrollment Period of at least 30 days.

It’s important to note that Open Enrollment and Special Enrollment Periods do not exist for Medi-Cal/Medicaid and the Children’s Health Insurance Plan (CHIP). Individuals can enroll in these types of coverage at any time, whether they qualify for a Special Enrollment Period or not.

Types of Qualifying Life Events

There are many different types of qualifying life events, but they fall into four broad categories: loss of health coverage, changes in household, changes in residence, and other miscellaneous events

The following are some examples of qualifying life events, grouped by category.

  • Loss of health coverage:
    • Losing existing health coverage, including job-based, individual, and student plans
    • Losing eligibility for Medicare, Medi-Cal/Medicaid, or CHIP
    • Turning 26 and losing coverage through a parent’s plan
  • Changes in household:
    • Getting married or divorced
    • Having a baby or adopting a child
    • A death in the family
  • Changes in residence:
    • Moving to a different ZIP code or county
    • A student moving to or from the place they attend school
    • A seasonal worker moving to or from the place where they live and work
    • Moving to or from a shelter or other transitional housing
  • Other qualifying events:
    • Changes in income that affect the coverage a person qualifies for
    • Gaining membership in a federally recognized tribe or status as an Alaska Native Claims Settlement Act (ANCSA) Corporation shareholder
    • Becoming a U.S. citizen
    • Leaving incarceration (jail or prison)
    • An AmeriCorps member starting or ending their service

These are just some of the more common examples of qualifying life events, not a full and exhaustive list. Employees who want to find out whether they qualify for a Special Enrollment Period or report a qualifying life event can do so at the Covered California website.

Make Sure Your Employees Understand Special Enrollment

With Open Enrollment just around the corner, it’s important that your employees understand the enrollment windows for Covered California and Medicare coverage as well as their overall benefits package and options. You may also want to consider bringing an insurance vendor onsite to answer questions from employees and help you explain insurance product offerings clearly and accurately.