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What is a "Qualifying Life Event"?

 

By Martine G. Brousse (still not AI)

"The Medical Bill Whisperer"

Patient Advocate, Certified Mediator

AdvimedPro

 

June 11, 2024

 

Whether you meet the guidelines for a “Qualifying Life Event” can make a huge difference: you may be able to purchase or obtain a new health insurance policy outside of the usual Open Enrollment Period or be forced to wait it out.

Let’s see how you can qualify and what to do about it.

 

A.   Definitions

 

1.     A “Qualifying Life Event” is a change in your personal situation or financial circumstances that can make you (and/or dependents) eligible for a Special Enrollment Period, allowing you to enroll in health insurance outside the normal yearly Open Enrollment Period

2.     The “Open Enrollment period” covers the time period when people can usually enroll in, renew, or change health plans for the next year

·      For new Medicare members: the Open Enrollment Period starts 3 months before your birthday month, and ends 3 months later

·      For established Medicare members: Oct 15 to December 15, every year

·      For Employer plans: the company can determine details of coverage and deadline to apply or change one’s plan, but most of the time, the enrollment period is in Nov to early December, for coverage starting the following Jan 1st.

·      For Marketplace plans (“Obamacare”): open enrollment is Nov 1st to Jan 15. Enroll by 12/15 for coverage starting Jan 1st, or enroll by Jan 15 for coverage starting Feb 1st.

 

B.    Qualifying Life Events: you can apply for and enroll in a new plan

 

1.     Loss of current health coverage (up to 60 days ago or in the next 60 days)

·      You quit your job

·      You were fired (except illegal activities)

·      You lost your Medicaid coverage due to a higher income

·      A child lost their CHIP coverage (in families with incomes too high to qualify for Medicaid, but too low to afford private coverage) due to age (turned 18) or higher income

·      The main policy subscriber became eligible for Medicare

·      The main subscriber passed away

·      You no longer qualify for Student health insurance

 

2.     Changes in Household

·      There is a new baby, a new adopted child, new foster child or new stepchild to be added to the policy

·      You got married and want to join your spouse’s plan

·      You got separated or divorced and lost your spouse's coverage

·      You turned 26 and can no longer stay on your parents’ policy

·      You are no longer a dependent on your parents’ IRS returns

 

3.     Change in residence

·      You moved to a new ZIP code or county

·      You are back in the US after living overseas

·      You moved to a difference school

·      You moved from or into transitional housing

. You were released from incarceration less than 60 days ago

 

4.     Unusual Circumstances 

·      A serious medical condition prevented you from enrolling on time

·      A natural disaster or national/state-level emergency kept you from enrolling on time

·      You were given incorrect or misleading info from a person working in an official capacity to help you, preventing you from enrolling on time or at all

·      The enrollment website shows incorrect information, preventing you from enrolling on time or at all

·      Technical issues prevented the completion of your application in time or at all

·      You had applied for Medicaid or CHIP (for your child), but your application was rejected after Open Enrollment Period ended

·      A Court order forces a dependent to be enrolled

·      You must get a separate policy from your abusive or violent spouse 


Please note: Changes in coverage must be made within 30 calendar days following the qualifying life event date, except for loss or gain of Medicare, Medicaid and CHIP (Children’s Health Insurance Program) which must be made within 60 calendar days following the loss/gain coverage date, even if the supporting documentation (or the SSN for a newborn) is not yet available 


C.    Where to apply (or appeal):

 

1.     Medicare members:

·      Get personalized and free assistance with a Navigator from SHIP (State Health Insurance Assistance Program) or contact Medicare directly

2.     Private employers’ plans

·      You are usually eligible for a program called COBRA, under which your employer is obligated to continue your coverage  for you and/or your dependents for 18 months (sometimes 36) but you might be responsible for payment of premiums

·      The HR department has to provide you with COBRA information and an application when you leave your job, either after you quit or after you were fired.

·      Be aware! If you stop COBRA coverage because of financial concerns outside of the Enrollment Period to switch to a marketplace plan, you will de denied, as voluntary cancellation of COBRA is NOT a “Qualifying Event”

3.     Marketplace plans (“Obamacare”)

·      Enrollment can be done online through Healthcare.gov, or via your State’s own exchange website if applicable

·      Free Navigators are also available to help guide you through the application or Special Enrollment/Qualifying Event application

·      Consult Healthcare.gov or call 800 318 2596 for info or assistance

 

 

A client was able to obtain a Marketplace plan in the middle of the year, outside of the Open Enrollment Period, as his “qualifying Event” was a hurricane that rocked his state, prompting



a local State of Emergency. Being aware of such exemptions is always smart, one never knows when they might come in handy.

As for Medicare and Marketplace navigators, they are well-trained, competent and vetted, have no financial incentive to sell you one plan or another, and are paid by your tax dollars. I have used a couple myself, and can only recommend their services.

 

 

 

Martine Brousse was a long-time Billing Manager for Physicians before switching to the side of patients in 2013. The move has allowed her to apply her deep expertise and vast experience of the intricacies of resolving all types of medical bill and claim payment issues in ways that directly and positively impact her clientsʻ finances.

 

(424) 999 4705 - F (424) 226 1330

@martine brousse 2024 @ the medical bill whisperer 2024

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