February 22nd, 2017

Now that open enrollment for health insurance is over, people want to know what will qualify them for a special enrollment period. Meaning what are the events that may come up for me that will allow me to make changes to my health insurance plan.


Here is a handy chart that outlines when members can make changes to their health insurance plans:
QUALIFYING LIFE EVENT 
OPTIONS


CHANGE IN FAMILY SIZE 
Marriage

• You may enroll in new coverage for you and/or your spouse.
• You may change your coverage to add new dependents.
• You may cancel coverage if you become covered by your spouse’s plan.

Dissolution of marriage
(includes divorce, annulment and legal separation)

• You may enroll in new coverage if you lost your coverage in the separation.
• You may change coverage if your dependents lost coverage in the separation.
• You must remove your former spouse from your policy.
• You may not remove dependents from your policy unless they become covered by your former spouse’s policy.

Death of spouse

• You may remove your spouse from your coverage.
• You may enroll in new coverage if the death caused you to lose your coverage.
• You may change your coverage to include dependents who lost coverage due to the death.

Birth/Adoption/Placement for adoption

• You may enroll yourself, your spouse and your dependents.
• You may change your plan to reflect the new size of your family.
• You may cancel coverage if you become covered by your spouse’s plan.
• Newborn added during SEP has coverage from day of birth applied retroactively.

Pregnancy
(New York only)

• You may enroll in coverage as of the first month of pregnancy.

Dependent moves to own policy

• You may remove a dependent from your policy.

Dependent becomes ineligible at age 26

• You may remove a dependent from your policy.

Dependent’s  death

• You may cancel enrollment for the deceased dependent.

CHANGE IN EMPLOYMENT STATUS
Job change within the same organization
(includes promotion, demotion and transfer)

• You may change coverage if your current plan is no longer available to you in your new position.

Loss of employment

• You will be insured through the end of the month.
• You may continue your employee coverage through COBRA at your own expense for 18 months.
• You may enroll in your spouse’s health plan, if available.

Loss of full-time status
(30-39 hours per week)

• No change is permitted.

Loss of full-time status 
(20-29 hours per week)

• You may cancel coverage for yourself and family members.
• You may change your coverage.

Loss of full-time status
(0-19 hours per week)

• If your employer does not provide insurance for part-time employees at this level, you coverage will lapse at the end of the month.
• You may continue your employee coverage through COBRA at your own expense for 18 months.

Newly benefit-eligible

• You may obtain new coverage for yourself and for your family members.

Part-time to full-time

• You may obtain new coverage for yourself and for your family members.

Spouse loses employment

• You may enroll yourself and eligible family members in a plan if the job loss caused you and your dependents to lose insurance.
• You may change your plan if you’re adding dependents that lost coverage.

Spouse becomes employed

• You may cancel your coverage if you or your dependents become covered under the spouse’s new plan.

Spouse’s employment status changes

• You may enroll in a plan if the change caused you or your dependents to lose insurance.
• You may add dependents to your plan if the change caused dependents to lose insurance.
• You may change or cancel your plan if the change causes the spouse’s insurance to be a better option for you or your dependents.

Retirement
(with no retiree health benefits from former employer)

• Coverage will cease at the end of the month.
• You may enroll in Medicare, if eligible.
• You may continue your employee coverage through COBRA at your own expense for 18 months.
• You may enroll in a Marketplace or individual health insurance plan.

Spouse loses traditional or retiree coverage

• You may add your spouse to your coverage.
• You may change your health plan.

Begin unpaid leave from work
(30+ days)

• You may change your coverage.
• You may cancel your coverage.

Return from unpaid leave
(30+ days)

• You may change your coverage.

Return from military leave

• You may enroll yourself, spouse and dependents to your coverage.
• You may change your health plan.

CHANGE IN RESIDENCE
Change of residence

• You may cancel coverage if you, your spouse or a dependent has become ineligible for your insurance due to a move.
• You may change coverage if you, your spouse or a dependent has become eligible for your insurance due to a move.
• You may add or change coverage if you or a dependent have become ineligible for your spouse’s insurance due to a move.

MEDICARE or MEDICAID ELIGIBILITY
Become eligible for  Medicare or Medicaid

• You may cancel private coverage for the person who has enrolled in Medicare.

Lose eligibility for Medicare or Medicaid

• You may add coverage for the affected family member.

OTHER
Court order

• You may add, change or suspend coverage if a court order or other official decree requires it.

Significant coverage changes

• You may change plans if services are drastically curtailed; for instance, if a large health network opts to stop accepting your insurance.

Changes in your income that affect the coverage for which you qualify (Marketplace plan)

• You may make changes to current coverage plan.

Become a U.S. citizen (Marketplace plan)

• You may enroll in coverage.

Leaving incarceration - prison or jail
(Marketplace plan or with private insurer)

• You may enroll in coverage.

Survivor of domestic abuse/violence or spousal abandonment
(Marketplace plan)

• Enroll yourself and your dependents in your own health plan separate from your abuser or abandoner. (If you are married to abuser/abandoner, you can list “unmarried” without penalty for mis-stating your marital status.)

Had a serious medical condition or natural disaster that kept you from enrolling
(Marketplace plan)

• Can enroll you and dependents in health plan if unexpected hospitalization, temporary cognitive disability or natural disaster (e.g. earthquake) kept you from enrolling.

WHO DOESN’T NEED A QUALIFYING EVENT?

Medicaid enrollment

• No limited enrollment period. If you qualify, you can apply at any time and coverage will begin immediately.

CHIP (Children’s Health Insurance Program) enrollment

• No limited enrollment period. If you qualify, you can apply at any time and coverage will begin immediately.

American Indians & Alaska Natives
(Marketplace plans)

• Under the Indian Health Care Improvement Act, American Indians can enroll anytime during the year.

*OregonHealthCare.us works to keep an updated and comprehensive list; however, the special enrollment chart shown may not apply to every benefit plan (especially dental and group life insurance that may be included in your workplace plan) and individual circumstances should be verified with your health insurance administrator.