qualifying event

What is a qualifying event?

A qualifying event is an event that triggers a special enrollment period for an individual or family to purchase health insurance outside of the regular annual ACA open enrollment period.

This article will help you understand more about qualifying events. And our guide to special enrollment periods has detailed information about all of the qualifying events that apply to coverage obtained in the individual/family market (on-exchange or off-exchange).

What types of health insurance use qualifying events?

Qualifying events trigger special enrollment periods in all ACA-compliant major medical plans. These types of policies include individual market, small group, and large group insurance plans – all of which have to allow you or your family member to enroll or make a plan change due to a qualifying event, assuming you meet all other eligibility requirements.

Qualifying events also apply to plans that are semi-compliant with the ACA (grandfathered and grandmothered plans). Certain qualifying events also trigger special enrollment periods for Medicare coverage.

Other types of policies (e.g., short-term medical plans) are not required to enroll you in coverage when you experience a qualifying event.

What are examples of qualifying events?

In the individual/family market (in most cases, this includes on-exchange or off-exchange coverage), qualifying events include:

• birth or adoption of a child
• marriage (and divorce, if the exchange or insurer counts it as a qualifying event, or if the divorce triggers a loss of other coverage)
• loss of other coverage (as long as the coverage you’re losing is considered minimum essential coverage)
• a permanent move to an area where different health plans are available (as long as you already had coverage prior to the move)
• a change in income that changes your subsidy eligibility (may not apply off-exchange in states that run their own exchanges)
• an increase in income that moves you out of the Medicaid coverage gap
• a grandfathered or grandmothered plan’s non-calendar-year renewal
• becoming a U.S. citizen or lawfully present resident (only applicable in the exchange)

The qualifying events in the employer market are slightly different than these events listed above.

How long do I have to select a plan or switch to a different plan if I experience a qualifying event?

If you experience a qualifying event, you have 60 days to select a plan in the individual/family market or switch to a different plan (in some cases, the ability to switch from one plan to another is limited during special enrollment periods). Depending on the qualifying event, you may have a special enrollment window that begins 60 days before the event and continues for 60 days after the event.

In most cases, the coverage will be effective the first of the following month if you enroll by the 15th of the month (HealthCare.gov will no longer impose this deadline as of 2022). But there are different effective date rules for marriage, birth or adoption of a child, and loss of other coverage.

For Medicare coverage, most qualifying events trigger 2-month special enrollment periods, but there are exceptions.

The length of time to select a plan usually is only 30 days in the employer market.