Understanding a Health Insurance Qualifying Event

What Is a Group Health Insurance Qualifying Event?

Nearly 50% of the total American population is covered through employer-sponsored health insurance, or group health insurance. While many employees are adequately covered throughout the year, some may feel the need to extend or reduce their benefits.

Adjustments to group health insurance plans are only allowed during open enrollment. However, certain qualifying events may allow an employee the option to adjust their coverage as needed outside of open enrollment. Learn what qualifies as a health insurance qualifying event and what your options are.

Health Insurance Qualifying Event

A health insurance qualifying event is an event that allows employees the chance to adjust their employer-provided healthcare benefits for themselves and any qualified dependents.

Employers or their group coverage provider determine the official dates of open enrollment. Only during this window can coverage be added, removed, or adjusted. If you’re an employee eligible for group health insurance and miss the open enrollment window, you may be forced to go without coverage until enrollment opens again — unless you experience a health insurance qualifying event. Below is a list of some of the most common life events that can open a temporary coverage adjustment window for employees.

  • The birth or adoption of a child
  • Marriage or divorce
  • A death in the family (either the policy holder or an insured dependent)
  • Change in residence (if current insurance does not cover new area)
  • Involuntary loss of coverage
  • Aging out of parental coverage

If a life event is ruled as a health insurance qualifying event, you will have 30 days (check with your employer) from the start of the event to adjust your current plan or enact additional coverage.

What Doesn’t Count as a Health Insurance Qualifying Event?

There are certain scenarios that may seem like a qualifying event but will not result in an open window. Here are some examples.

  • You and your spouse are going through a divorce. You each have your own coverage through your employers and have no children. You are not likely to qualify for a temporary open window.
  • A family member passes away who is not included in your current family plan. Any dependents on the deceased’s insurance plan will likely earn an open window but you are not likely to.
  • You purchase a new home several towns over and move. You don’t change jobs and your health plan is still available in your new zip code. You’re are not likely to qualify for a temporary open window.

What If You Miss Your Special or Open Enrollment?

If you miss your employer’s open enrollment window and don’t have insurance, you’re not out of luck yet. You have a few options to consider.

You may qualify for federal programs like Medicaid or the Children’s Health Insurance Program. If your income surpasses the requirements for these programs, you can look into membership health insurance or short-term health insurance.

While never recommended, you may be forced to go without coverage. Should you be unable to secure insurance, start an emergency health fund to cover your medical costs.

Learn More

If you’re experiencing a life change that you believe is a health insurance qualifying event, don’t put off learning about your options. Turn to your employer’s HR department or service to learn about your options. And if you’re an employer, educate your employees about qualifying events and remember that it’s never too early to start preparing for open enrollment.

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