What is Considered a Qualifying Event for Group Health Insurance? (2024)

If you’re facing a major change in your life, like getting married, losing your job or having a child, you may be able to make changes to your group health insurance coverage.

These events are called qualifying events and are typically referred to as special enrollment periods (SEPs). They allow you to enroll in a new ACA-compliant plan or make a plan change outside of the regular annual open enrollment period.

Birth or adoption of a child

The birth or adoption of a child is one of the most common qualifying events for group health insurance. Adding a new child to your family can be very exciting, but it’s also a big responsibility.

When your child is born, you can add them to the coverage offered by your employer’s plan. You may also be able to enroll in your employer’s flexible spending account (FSA), which allows you to set aside tax-free dollars for out-of-pocket medical expenses and dental or vision care.

Generally, a qualifying life event triggers what’s known as a special enrollment period for Marketplace plans. These special enrollment periods allow you to enroll in an ACA-compliant plan outside of the annual open enrollment period, which runs from November 1 to January 15.

Change in marital status

If you have recently married, divorced, or separated, you may want to review your financial situation. A change in your marital status can affect your filing status, the income you report, and the deductions you can claim.

A change in your status can also affect your insurance coverage. Some group health policies allow spousal coverage, which can save you money and provide more benefits than separate individual plans.

Adding your spouse to your coverage can be done by making a Family Status Change Request. You will need to submit a change form and a copy of your marriage certificate or divorce decree within 30 days.

You must notify your employer of the change in marital status, or any other event that is considered a qualifying event for group health insurance within 30 days after the life event occurs. If you do not notify your employer, the change will not be effective and you will have to wait until the next Open Enrollment period.

Loss of employer-provided coverage

In the United States, the most common source of health insurance is employer-sponsored. It covers more than 150 million Americans and their dependents, compared to 70 million insured through Medicaid, 50 million insured through Medicare, and 17 million insured through the Affordable Care Act marketplaces or the individual market.

Employer-sponsored plans are also the only kind of coverage available to many small businesses. These plans are usually tax-advantageous because the employer and employees share the costs, reducing the employee's taxes.

Group health insurance is offered by employers, associations and affinity groups such as unions or fraternal organizations. These groups can offer a wide variety of plan options to their members and employees, but most policies require 70% participation.

Change in residence

There are many different kinds of events that are considered a qualifying event for group health insurance. These include birth or adoption of a child, gaining new employment, and changing residences.

In some cases, you may also qualify for a special enrollment period (SEP) if you move out of the service area of your HMO or switch to a Medicare Advantage plan in your new location. In these cases, you will have 60 days to notify your provider and select a new plan.

During the SEP, you will have more plans to choose from and your coverage can be adjusted as needed.

While residency can be established by physical presence in a jurisdiction, it is more difficult to prove domicile. This is usually achieved by having a true permanent home and by establishing social, civic and religious connections in the state. Other forms of paperwork, such as updated credit card and bank account statements or tax filings, are also important in determining residency.

What is Considered a Qualifying Event for Group Health Insurance? (2024)
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