What is a qualifying life event for special enrollment?

You can only sign up or make changes to your health insurance coverage during the open enrollment period, unless you experience a qualifying life event, such as getting married or having a child. Such major life events allow for a special enrollment period where you can make changes to your health insurance policy.

Here’s more about when you may be eligible to make coverage changes outside of open enrollment, what you can do, and advice to make the most of your health insurance options.

What is a qualifying life event?

Qualifying life events are life-changing events in your household, residence or other health insurance coverage that make you eligible to change your coverage outside of open enrollment. 

The rules are slightly different for employer plans than they are for coverage you buy on your own at Healthcare.gov or your state health insurance marketplace.

“There are a number of different ways to configure your coverage as your life changes,” says Alan Silver, senior director and actuary, health and benefits, for Willis Towers Watson, a benefits consulting firm. “Every time you qualify for a life event, you should do a full review of what benefits are available to you and ensure that you’re maximizing your benefits for the lowest cost possible.”

How a qualifying life event works

If you experience a qualifying life event, you’re eligible for a special enrollment period to buy health insurance or make changes to your coverage outside of the annual open enrollment period.

You usually have 60 days from the qualifying life event (such as marriage) to make the change. The timeframe can vary based on the event and the type of coverage. Also, some deadlines have been extended because of the COVID-19 emergency. 

Employer plans, however, may limit the types of changes you can make when you have a qualifying life event. 

“Employers don’t have to allow for a full special enrollment where all benefit options that were available at open enrollment are back on the table — most employers don’t,” says Silver. “They only allow for changes in the coverages you’ve already selected.” 

For example, if you have a baby, the employer may give you the option to add your child to your existing coverage or drop your coverage altogether and enroll somewhere else, he says.

Types of qualifying events

You can qualify for a special enrollment period at Healthcare.gov if you experience these qualifying life events. Here are examples of qualifying life events:

• Marriage
• Birth or adoption
• Death of a spouse or dependent
• Job loss
• Job change
• Retirement
• Work hours reduction
• Moving

Your state may offer additional rules for life events that create a special enrollment period.

What if you don’t have a qualifying life event?

If you don’t have a qualifying life event, you usually must wait until the next open enrollment period to change your coverage. However, you can drop marketplace coverage at any time.

If you qualify for free or low-cost coverage through Medicaid or the Children’s Health Insurance Program, you can enroll in those programs at any time. The income requirements and other eligibility criteria can vary by state.

Can I drop my health insurance without a qualifying event?

You can drop your individual health insurance plan anytime during the year without any qualifying event. However, you need to experience a qualifying life event to cancel group health insurance through your employer.

What kind of documents do you need for qualifying life events?

You generally need to provide proof of the qualifying life event, such as:

• A marriage license
• Adoption papers
• Utility bills or a lease or mortgage documents if you move
• A letter from your employer or insurance company if you lost coverage

See the Marketplace documents list at Healthcare.gov for details and deadlines.

The required documents can vary if you have employer coverage. 

“Many require some form of documentation for a new dependent (a birth certificate or an official documentation of a marriage, for example), but some employers just require an affidavit,” says Silver. 

He adds that many employers recently started asking for more documentation to make sure they’re only covering eligible dependents.

What to do if you qualify for a special enrollment period

If you have new choices — after you get married, for example — compare all of your options when deciding which coverage is best for you, especially if both spouses work and have health insurance through each of their employers. 

“Look at everything — the plan designs of each member of the family, the costs out of their paycheck for each individual scenario, how often the participants use coverage, what kind of prescription drugs they use,” says Silver.

Silver adds that you may want to look for the lowest cost alternative for you. It may mean going with separate single coverage rather than a couple or family plan. 

“That may mean everyone on the same plan, but very often for two people working full-time, it might mean each spouse enrolling separately, with a separate conversation around the merits of which plan is right for the children,” Silver says. 

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