What is a qualifying event?

Outside of the open enrollment window, there are very few options for health coverage that can be purchased before November 1 (when the next open enrollment begins in the individual/family market), unless you have a qualifying event.  And most of the plans that can be purchased outside of open enrollment are not suitable to serve as your only health coverage – many of them are a good supplement to a major medical policy, but they cannot be thought of as good coverage on their own. Many of our clients have now found themselves unable to apply for ACA compliant health insurance coverage and asking “What is a qualifying event?” If you have a qualifying event that triggers your own special open enrollment window, you can purchase an ACA-compliant major medical health insurance policy outside of the general open enrollment window.

Open enrollment and qualifying events are a new concept in the individual market, although they’ve long been part of the group market.  A lot of the qualifying events in the newly-reformed individual market will seem familiar to those who are used to the group market, but some are specific to the new individual market. In Colorado, applications completed during a special open enrollment window will have a first of the following month effective date if they’re submitted by the 15th of the month, and a first of the second following month if they’re submitted between the 16th and the end of the month (so for example, if you apply for a new plan on June 21, your new policy would be effective on August 1).  But there are a few exceptions:  Marriage, loss of other coverage, and birth/adoption/placement for foster care have special effective date rules, which are described below.

What is a qualifying event? The following events trigger a special open enrollment window:

  • Involuntary loss of other coverage (note that you cannot simply cancel your old plan or let it lapse by not paying the premium – that is not an involuntary loss of coverage).  In order to qualify for a special open enrollment window, the coverage that’s ending must be minimum essential coverage.  So for example, if you have a short-term policy that is ending, your loss of coverage does not count as a qualifying event and there’s no special open enrollment.  Connect for Health Colorado will allow anyone with individual or employer-sponsored coverage that is ending within the next 60 days to enroll up to 60 days in advance of the termination date in order to avoid a lapse in coverage.  There is also a 60-day open enrollment window following the loss of coverage.
  • Divorce.  If a divorce results in a loss of coverage, you have 60 days during which you can enroll in a new plan under the “Involuntary loss of other coverage” event explained above.

What is a qualifying event

  • Becoming a dependent or gaining a dependent as a result or birth, adoption, or placement in foster care.  You have 60 days to complete the enrollment, but coverage is retroactively effective as of the date of birth, adoption, or placement in foster care (EDIT, 6/17/2014:  New regulations (see page 30296) allow parents the option to choose a different effective date).  The current regulation states that anyone who “gains a dependent or becomes a dependent” (ie, the parents and the new child) is eligible for a special open enrollment window.  But Connect for Health Colorado has said that they will accept an application for the whole family (the Federally Facilitated Marketplace also accepts applications for the entire family).
  • Marriage.  A 60 day open enrollment window is available following a marriage.  The policy will be effective the first of the month following your application, even if the enrollment is completed after the 15th of the month.
  • Becoming a US citizen, when there is no previous lawfully present immigration status.
  • A permanent move to an area where different QHPs are available.  Anyone moving into or out of Colorado has access to special open enrollment, but even if you are already a Colorado resident and are moving within the state, you may qualify for special open enrollment.  Not all QHPs are available in all areas of the state.  Kaiser Permanente, Bright Health, Denver Health Medical Plan (Elevate), and Cigna are examples of plans that are available in some parts of Colorado but not others.  If you move within the same zip code, your health plan options will likely stay the same.  But if you move across the state, there’s a good chance your move is a qualifying event that triggers a special open enrollment.
  • An error or problem with enrollment (or non-enrollment) that was the fault of Connect for Health Colorado, a carrier, or an enrollment assistor.  If you experienced a problem with enrollment during regular open enrollment, contact us or Connect for Health Colorado as soon as possible in order to remedy the situation.
  • Employer-sponsored coverage becoming unaffordable (by ACA definitions) or cutting benefits to the point that it no longer provides minimum value.  (The ACA defines “affordable” as not costing more than 9.5% of income for only the employee’s portion of the coverage).  If you’re in this situation, you’ll have a special open enrollment window for 60 days before and after the date that your employer plan renews, so you can purchase a new individual plan with no lapse in coverage if you utilize the advance open enrollment window.  Note that this situation is rare.  Although most employer plans increase premiums each year, it’s relatively unusual for just the employee’s portion of the premium to exceed 9.5% of income (unfortunately, it’s common for family premiums to exceed that mark, but that does not trigger a special open enrollment, nor does it trigger subsidy eligibility in the exchange).  And most employer-sponsored plans do provide minimum value and will continue to do so.
  • EDIT, 6/17/2014:  New regulations (see page 30296) released at the end of May added a couple of additional qualifying events and section 155.420 of the code of federal regulations has been updated accordingly:
  • For people who have individual policies that do not follow the calendar year (ie, they renew at a time outside of the regular open enrollment window established by the ACA), the end of the plan year is a qualifying event that triggers a special open enrollment window.  So even if your existing plan is renewing instead of terminating this year (possible as a result of the Obama Administration’s announcement in March that pre-2014 plans could be extended for up to two more years), you still qualify for a special open enrollment window when your existing plan is up for renewal – you can opt to cancel it instead and switch to an ACA-compliant plan.
  • Women who lose access to pregnancy-related Medicaid coverage have the same special open enrollment window for purchasing an ACA-compliant plan as someone who is losing coverage that is considered minimum essential coverage.  This is despite the fact that coverage only for pregnancy-related services has been deemed not minimum essential coverage.

Some qualifying events apply only to people who are already enrolled through Connect for Health Colorado:

  • Special open enrollment is available if you’re enrolled in a QHP that “substantially violated a material provision of its contract in relation to the enrollee.”  There is an official process for this, and the violation has to be “substantial.”

In some cases, year-round enrollment is available without qualifying events:

  • Medicaid enrollment is also year round.  If you’re already enrolled in Medicaid and your income increases above the Medicaid eligibility level, you’ll have a special open enrollment window triggered by the “loss of other coverage” event explained above.
  • Employers can purchase SHOP plans year-round (employees will be subject to the normal open enrollment rules in the group market).