What Is A Qualifying Event For Health Insurance

| February 12, 2013 | 0 Comments
Short Answer: To understand a qualifying event for Qualifying Event For Health Insurancehealth insurance, first we need to understand the concept of the term “open enrollment”. Now if you are employed with a company, I am sure you have come across this term at least once every year. “Open enrollment” means that each year you are given a specified time frame (period) to modify, add or drop your health insurance coverage. During this open enrollment period, whatever decision you make will have to be followed for the complete year until the next open enrollment period comes by. The exception to this condition is a qualifying event for health insurance.

If we have to simply describe a qualifying event for health insurance in one word then the word would be “Exception”. The exceptions like marriage, sudden unemployment or parenthood allows you to modify your health insurance coverage outside the open enrollment period.

Just to make you aware, the open enrollment period this is would start from October 2013 and will run until March 2014. Next year you would not get this long levy as the enrollment period would be reduced to half. Probably from October till December 2015.


What Are Various Qualifying Events For Health Insurance Changes

Majority of the people who need better understanding of a qualifying event for health insurance changes are employed. The general consensus is that a qualifying event is the occurrence of an event which triggers COBRA if the employee loses his/her job.

Mentioned below is the list of qualifying events for health insurance:

  1. Any change in your legal marital status which includes divorce, marriage or annulment.
  2. Any change in the number of dependents in your health insurance plan including birth, death or adoption.
  3. Any change in your employment status or your spouse or any change in the employment status of dependents will also trigger a qualifying event. The change includes termination or commencement of a job. Change or return from an unpaid leave of absence. Change in place of work or situation (hourly or weekly salary changes).  All this is also applicable to your spouse’s employment or dependents employment conditions.
  4. Any dependent which does not satisfy eligibility requirements due to attainment of age, student status or similar qualifying events.
  5. Any changes in cost of coverage.
  6. FMLA (Family Medical Leave Act) Leave.
  7. Judgments, orders and decree’s trigger a qualifying event for health insurance changes.
  8. Any changes in the coverage of your spouse or dependent from another employer plan.
  9. HIPAA (Health Insurance Portability and Accountability Act) special qualifying events for dependents and due to loss of coverage in insurance. We will discuss this in detail down below under qualifying events under HIPPA.
  10. Qualifying events for health insurance under COBRA. Discussed below.
  11. Qualification under Medicaid or Medicare.
  12. Loss of coverage under a group health plan of the federal government like state sponsored health insurance programs, CHIP (Children Health Insurance Program), state health risk pools etc.


Qualifying Events For Health Insurance Under COBRA


Events applicable to covered employee and their dependents.

  • Termination of employment due to voluntary or involuntary reasons. Except misconduct.
  • Notable changes in your working hours.

Events applicable to covered spouses and their dependents.

  • Death of an employee
  • Divorce or legal annulment
  • Loss of dependent status as stated above due to age restrictions and attaining student status
  • Employee becomes eligible for Medicaid.

Qualifying Events For Health Insurance Under HIPPA


Utmost care has been taken to make this information as accurate as possible. Should you have any doubts regarding the same, please consult your HR representative or an insurance agent for detail clarification.

The HIPPA (Health Insurance Portability and Accountability Act) act of 1996 makes it mandatory for group health insurance plans to make provisions for special enrollment for their employees and their dependents under specific scenarios. Let us examine these special conditions and arising situations:

  1. Loss of other employer based coverage
  2. Loss of eligibility for the group health plan. This may be due to the following reasons:
    Termination of employment.Dependents loss of eligibility due to age.Change in marital status.

    Members moving out of the services.

    Members moving out of the serviced area of HMO plan.

Termination of employment.

Death of an employee.

Termination of domestic partnership agreement.

Any qualifying event for health insurance must be reported to your health insurance company within 60 days of occurrence to be eligible for changes.

Image Courtesy: Steve Rhodes



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