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What is Considered a Qualifying Event When Buying Health Insurance?

What is Considered a Qualifying Event When Buying Health Insurance?

Mar 01, 2023

When it comes to health insurance, there is a limited period of time when one can purchase the policy or make changes to its coverage. This time frame is what we call “open enrollment”, which typically falls between November 1st and January 1st (of the following year). During open enrollment, policyholders or soon-to-be policyholders can make changes to their coverage or purchase a new plan. 

The one issue with the open enrollment timeframe is that it only allows changes in one’s coverage for 2-3 months out of the year. However, life is unpredictable, and you may need changes in your healthcare policy at other times of the year. The solution to this is called a “qualifying event”, which essentially allows you to make the necessary changes to your policy as long as you meet the standards.

In today’s article, we are going to discuss the different types of qualifying events so that you can change your coverage to meet your specific needs at any time of the year.  

Defining a Qualifying Event

The term qualifying event refers to a specific life change that allows individuals and families to enroll in or change their health insurance coverage outside the annual Open Enrollment Period. If these qualifying events did not occur, individuals and families would be limited to enrolling in health insurance coverage only during the annual Open Enrollment Period. 

Qualifying events make it possible for people to enroll in coverage or make changes to their coverage when they experience a change in life circumstances that affects their health insurance needs.

Here is a breakdown of the supported qualifying events:

  • Loss of coverage
  • Change in residency
  • Changes in household members
  • Loss or change in income
  • Other

It is important to understand what each of these means in terms of a qualifying event so that you can change your policy coverage when significant life events happen. 

Loss of Coverage

Special enrollment periods are triggered when an individual loses coverage involuntarily. If you lose coverage to your health insurance plan due to a qualifying event, you might be able to sign up for a new one with no coverage gap. In this case, it must be deemed a loss of minimum essential coverage to be considered a qualifying event. For example, short-term plans are not considered minimum essential coverage, so dropping them does not count as losing coverage.

An example of when you would qualify for a change in your policy will be if you lose your employment-based insurance. Employer-sponsored plans provide coverage to most non-elderly adults. As a result of leaving their employer, whether voluntarily or involuntarily, they lose access to their employer-sponsored health insurance. Consequently, if you leave your job and lose your health insurance, you can enroll in a new plan in the individual market during the special enrollment period

It is also important to note that certain factors will prohibit you from using a loss of coverage as a qualifying event. One of these factors is a recession. This is because, during a recession, many individuals may lose their healthcare coverage, meaning the government will have to take “loss of coverage” off the list of available possibilities for individuals to make healthcare changes outside of the open enrollment period. 

Change in Residency

Sometimes moving to a new location can impact your healthcare coverage. This is because not all plans are covered in all areas, meaning that when you relocate, there is a possibility you will lose or have an impact on your current policy. 

As a good illustration, depending on the state where one moves, an individual or family may have access to different health plan options and distinct types of financial assistance. It is also possible that they will lose access to their current health insurance plan if the state in which they relocate does not offer it.

Even if an individual or family does not move to a new state, they may still experience a change in health plan options if they relocate to a different region or zip code. A new area, for example, may offer different Medicaid or CHIP coverage options due to the availability of other insurance companies.

Changes in Household Members

Another example of a possible qualifying event for health insurance in Florida is the change in the number or needs of household members. A change in household size is a qualifying life event, which includes marriage, divorce, having a baby or adoption, the death of a family member, and family changes ordered by a court.

If an individual gets married or divorced, they may become eligible for different health insurance options through their new spouse’s plan or the Marketplace. In some cases, they may also lose access to their current plan if it was through their former spouse’s employer.

You will also qualify to change your policy if you choose to adopt or have a baby. The existing health insurance of the parents typically covers a newborn or an adopted addition to the family however, it is also possible for parents to enroll in a different health plan or make changes to their current coverage.

Lastly, if a family member passes away, the remaining family members may become eligible for different health insurance options, either through a new employer or through the Marketplace. They may also lose access to their current plan if it was through the deceased family member’s employer.

Changes in Income

Sometimes changes in income occur and since health insurance in Florida costs money, it is important to add this possibility to the list of acceptable qualifying events so that if you lose your income, you can purchase an affordable policy. 

For example, a person may qualify for financial assistance through the Marketplace if their work hours or income are reduced. Additionally, in the event that a family’s income changes due to a new job, job loss, or other factors, they may be eligible for financial assistance to help pay for their health insurance premiums and out-of-pocket costs.

Individuals and families need to provide documentation to verify their income to enroll in or change health insurance coverage due to a change in income. These documents may include recent pay stubs, tax returns, or other financial information. 

Please contact the Marketplace or your insurance company for specific details, as documentation requirements may vary depending on the particular health insurance plan or program. Speaking directly to an insurance agent is always your best bet for understanding how to change or purchase a healthcare policy. 

How to Enroll in a Qualifying Event

When it comes to enrolling for a qualifying event, the process is dependent on why you qualify and the insurance coverage you have/had. You will most likely need to go through your independent insurance agency, Marketplace, or COBRA to be granted the means to change your policy outside of the standard enrollment period.

Health insurance coverage can be enrolled in or changed by individuals and families who experience a qualifying event within 60 days of the qualifying event date. To ensure coverage begins on the first day of the following month, enrollment should be made as soon as possible after the qualifying event.

The process of enrolling in health insurance coverage can be complex, and individuals and families may need assistance. In addition to trained navigators and licensed agents who can provide free assistance, the Marketplace offers a variety of resources for individuals and families to enroll in coverage. Also, many insurance companies have customer service representatives who can assist with enrollment and answer questions about coverage options.

How Del Toro Can Help

People and families who need to enroll in or make changes to their health insurance outside of the annual open enrollment period need to know what events qualify for special enrollment. A qualifying event can range from a change in employment to a change in household composition, and each event has its own eligibility criteria and documentation requirements.

Del Toro Insurance can aid individuals and families who have experienced a qualifying event and need to enroll in or make changes to their health insurance coverage.

As a licensed insurance agency, Del Toro Insurance can help individuals and families navigate the Health Insurance Marketplace and find the right health plan to fit their needs and budget. We can help individuals and families understand their coverage options, compare health plans, and apply for financial assistance to help pay for their premiums and out-of-pocket costs.

Del Toro Insurance can provide ongoing support to help individuals and families manage their health insurance coverage. We can help with tasks such as updating personal information, renewing coverage, and resolving issues with claims or billing.

You deserve an agency that truly cares about your and your family’s health. Contact one of Del Toro’s specialty insurance agents today and get the help you need regarding your health insurance policy

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