Employees often come to us throughout the year asking if they can change their plan, cancel their insurance, join a plan they aren’t on, etc. Insurance carriers are very strict regarding when you are allowed to enter, exit, or make changes to the group plan. Other than open enrollment (which is different for every company) or when you are first hired, you are only allowed to make changes if you have a qualifying event.
What is a QE?
Qualifying Events (QEs) are changes in your personal situation that cause you to become eligible for a special enrollment period. During that special enrollment period you are able to enroll in coverage if your not enrolled, terminate coverage if you are enrolled, add dependents that aren’t enrolled, remove dependents that are enrolled, or sometimes to change the plan that you are on to another plan.
What Counts as a QE?
These are the observed qualifying events for most carriers:
- Adoption (when you adopt, not when a relative does)
- Annulment, Divorce or Legal Separation
- Becoming a US Citizen or National or Lawfully Present Resident (entering the US as a permanent resident also counts for families moving to the US to live with a spouse/parent)
- Birth of a child (again, must be your own child)
- Change in cost of coverage (this typically doesn’t happen since price changes are during renewal)
- Court Order (this is typically for adding children when you have a court order for child support)
- Death (Hopefully this doesn’t happen but if you die, you’ll obviously be removed from the plan. If a dependent dies, it also counts as a QE)
- Gain of Custody of a Dependent
- Employment Status Change (for example: going from part time to full time)
- Gain/Loss of Eligibility for Medicare/Medicaid
- Loss of other Coverage or loss of dependent status (For example if you are on your parent’s coverage and you turn 26, you’ll be kicked off of their plan and must get onto your own insurance. This counts.)
- Gaining other coverage (if your spouse is in open enrollment, you are able to enroll in their plan and use that as a QE to cancel your other coverage)
- There are some exceptions to the rules such as if you have a change in financial situation and can no longer afford the coverage. In those cases, you can put in a request for removal from the plan as well. However, the above list is pretty comprehensive when it comes to what is allowed.
What You Should Know
If you have a qualifying event and wish to make a change, there are a couple of things you need to know. First, there is a specific time period during which you are able to make a change. You only have 30 days from the date of the event to make a change. If your child is born on 9/15, you have until 10/15 to submit the request for enrollment. You don’t want to get to 10/16 and have your newborn rejected by the insurance at a check up. If you try and submit paperwork after the 30 days you’ll either be rejected outright or you’ll have a much more difficult time getting enrolled. Most likely you’ll be rejected.
Second, if you have a qualifying event, be sure to keep copies of documents to provide proof of the event. For example, if you get married, have a copy of your marriage certificate. If you lose coverage, save the copy of the termination of benefits notice that you’ll get in the mail from your other coverage. You’ll need to submit this along with your change request form. You’ll have to work with your HR team to get all of the right paperwork submitted.
If you have questions or need help with your QE, ask your HR team or your broker.