Qualifying Life Events & Special Enrollment

An individual, under certain circumstances, may apply for coverage due to a qualifying life event (QLE). This is referred to as a special enrollment period (SEP). Documentation supporting eligibility under one of the QLEs listed below is required and must be submitted at the time of application.

Important: To be considered eligible in most cases, your application for coverage due to a QE must occur within 60 days of the QLE.

Important note: An eligible individual or dependent who experiences a loss of minimum essential coverage (MEC), has 60 days prior to and 60 days following the loss of coverage to enroll.*

The specific QLE may apply to your entire family, or only to the person affected. For example, if you had a newborn child, you could enroll the child as an individual effective on the child’s date of birth, or you could enroll your entire family effective on the newborn’s date of birth. Please be aware that the effective date differs based on the QLE. An SEP applies to new contracts and additions to existing contracts due to a QLE.
*Please note: The following is for reference purposes only and is not meant to portray a complete list of all QLE’s that might result in a SEP. Please contact your health plan representative for a current and complete list of QLE’s that apply to your particular circumstance.*

Effective date: The date of birth or the date the parent(s) have control of the health care of the child being fostered or placed for adoption (most times prior to the adoption being final). You may also opt for an effective date the first of the month after the qualifying event.

  • BIRTH
    • Birth certificate of the child (Hospital, county, or government issued only)
  • ADOPTION &/or Placement for Adoption:
    • Medical Authorization Form
    • Evidence of the enrollee’s right to control the health care of the child
    • Relinquishment Form
Effective date: The first day of the month after receipt of your request for enrollment. For example, an application received February 20 would have a coverage effective date of March 1.

  • Marriage certificate
  • Partnership agreement
Effective date: If the request is postmarked or received between the first and 15th of the month, coverage will be effective the first day of the next month. If the request is postmarked or received between the 16th and the end of the month, coverage will be effective the first day of the second following month.

  • Qualified Medical Child Support Order (QMCSO)
  • Valid state or federal court order that dependent is mandated to be covered
Effective date: The first day of the month after receipt of your application for enrollment. For example, an application received February 20 would have a coverage effective date of March 1.

  • COBRA, FMLA, or Cal-COBRA Election Form
  • Coverage cancellation notice, Model Notice, or Certificate of Creditable Coverage
  • Letter from employer on business letterhead confirming loss of coverage or reduction of hours of employment to less than the number of hours required for eligibility

Important! Qualifies under loss of minimum essential coverage (MEC) criteria. This means the request for coverage may be submitted up to 60 days prior to and up to 60 days following the actual loss of coverage effective date

Effective date: The first day of the month after receipt of your application. For example, an application received February 20 would have a coverage effective date of March 1.

  • COBRA, FMLA, or Cal-COBRA Election Form
  • Coverage cancellation notice, Model Notice, or Certificate of Creditable Coverage
  • Letter from employer on business letterhead confirming loss of coverage which is not COBRA

Important! Qualifies under loss of minimum essential coverage (MEC) criteria. This means the request for coverage may be submitted up to 60 days prior to and up to 60 days following the actual loss of coverage effective date

Effective date: The first day of the month after receipt of your application. For example, an application received February 20 would have a coverage effective date of March 1.

  • Certified death certificate (facsimile OK)
  • COBRA, FMLA, or Cal-COBRA Election Form
  • Letter from employer on business letterhead confirming loss of coverage
  • Obituary (newspaper copy &/or mortuary notice OK)
Effective date: The first day of the month after receipt of your application. For example, an application received February 20 would have a coverage effective date of March 1.

  • Copy of Medicare card
  • Approval letter of entitlement from
  • Social Security Office

 

And one of the following:

 

  • COBRA, FMLA, or Cal-Cobra Election form
  • Coverage cancel notice
  • Letter from employer on business letterhead confirming loss of coverage

Important! Qualifies under loss of minimum essential coverage (MEC) criteria. This means the request for coverage may be submitted up to 60 days prior to and up to 60 days following the actual loss of coverage effective date

Effective date: The first day of the month after receipt of your application. For example, an application received February 20 would have a coverage effective date of March 1.

  • Letter from employer on business letterhead confirming loss of coverage
  • Coverage cancellation notice, Model Notice, or Certificate of Creditable Coverage
  • Copy of letter from the carrier explaining reason for dependent cancellation

Important! Qualifies under loss of minimum essential coverage (MEC) criteria. This means the request for coverage may be submitted up to 60 days prior to and up to 60 days following the actual loss of coverage effective date

Effective date: The first day of the month after receipt of your application. For example, an application received February 20 would have a coverage effective date of March 1.

  • COBRA, FMLA, or Cal-COBRA Election Form
  • Coverage cancellation notice, Model Notice, or Certificate of Creditable Coverage
  • Letter from employer on business letterhead confirming loss of coverage

 

and one of the following:

 

  • Divorce decree
  • Notice of Termination of Domestic Partnership (notarized)
  • Other documentation supporting divorce or dissolution of domestic partnership
  • Important! Qualifies under loss of minimum essential coverage (MEC) criteria. This means the request
  • for coverage may be submitted up to 60 days prior to and up to 60 days following the actual loss of coverage effective date
Effective date: The first day of the month after receipt of your application. For example, an application received February 20 would have a coverage effective date of March 1.

  • Notification of loss of Children’s Health Insurance Program or Medicaid coverage from state program

Important! Qualifies under loss of minimum essential coverage (MEC) criteria. This means the request for coverage may be submitted up to 60 days prior to and up to 60 days following the actual loss of coverage effective date

Effective date: The first day of the month after receipt of your application. For example, an application received February 20 would have a coverage effective date of March 1.

  • Coverage cancellation notice, Model Notice, or Certificate of Creditable Coverage

 

and at least one of the following:

 

  • Current utility billing statement confirming the California address
  • Lease or rental agreement
  • Monthly mortgage statement
  • Monthly mortgage statement

Important! Qualifies under loss of minimum essential coverage (MEC) criteria. This means the request for coverage may be submitted up to 60 days prior to and up to 60 days following the actual loss of coverage effective date

Effective date: If the request is postmarked or received between the first and 15th of the month, coverage will be effective the first day of the next month. If the request is postmarked or received between the

16th and the end of the month, coverage will be effective the first day of the second following month

  • INFANTS & DEPENDENT CHILDREN (applying solo):
    • Birth certificate of the child (hospital, county, or government issued only) ~OR~ supportive documentation confirming the adoption or legal guardian status (as applicable)
  • SCHOOL-AGED CHILDREN (applying solo):
    • School enrollment record from the former state
    • California school enrollment record (school-aged child)
  • ADULT APPLICANTS & FAMILIES:
    • Verification of recent address change, such as a utility billing statement, rental agreement, or mortgage statement from the previous residence
  • Additionally, if moving from another country, please submit one of the following
    • Copy of Visa/passport information page and the date stamped page
    • Boarding pass showing name and entry date into the United States

 

and at least one of the following:

 

    • Current utility billing statement confirming the California address
    • Lease or rental agreement
    • Monthly mortgage statement
Effective date: If the request is postmarked or received between the first and 15th of the month, coverage will be effective the first day of the next month. If the request is postmarked or received between the

16th and the end of the month, coverage will be effective the first day of the second following month.

  • Certificate of Release or Discharge from Active Duty
  • Loss of minimum essential coverage*
  • Release from incarceration
  • Loss of coverage due to employer Chapter 11 activity from which the covered employee retired
  • His or her health benefit plan substantially violated a material provision of the contract
  • Advanced Premium Tax Credit (APTC) or cost-sharing eligibility change
  • Completion of covered services when contracting provider is no longer participating
  • Enrollment/non-enrollment in a qualified health plan was unintentional, inadvertent, or erroneous resulting from the error, misrepresentation, or inaction of the Exchange or the Department of Health and Human Services, or non-enrollment/not receiving advanced premium tax credits or cost sharing reduction as a result of a non-Exchange entity providing enrollment assistance/activities (both as determined by the Exchange)
  • American Indian status (may be entitled to a monthly special enrollment period)
  • New United States citizen (citizenship newly obtained)
  • Other exceptional circumstance (circumstance must be validated by Covered California)
  1. Legal separation†
  2. Divorce† or dissolution of domestic partnership
  3. Cessation of dependent status (such as attaining the maximum age to be eligible as a dependent child under the plan)†
  4. Death of an employee†
  5. Termination of employment†
  6. Reduction in the number of hours of employment†
  7. A covered employee becoming entitled to Medicare and a dependent loses coverage†
  8. A Proceeding under Chapter 11 with respect to the employer from whose employment the covered employee retired at any time†

Any loss of eligibility for coverage through Medicare, Medi-Cal, including loss of pregnancy-related coverage and medically-needy coverage, or other government-sponsored health coverage.

Loss of Minimum Essential Coverage does NOT include failure to pay premiums or rescission of prior coverage

Per the federal government and Covered California, a loss of minimum essential coverage (MEC) allows applicants to submit a request for coverage up to 60 days before and after the loss of coverage effective date. This is intended to avoid a coverage gap when switching to the new plan.

*Please note: The preceding is for reference purposes only and is not meant to portray a complete list of all QLE’s that might result in a SEP. Please contact your health plan representative for a current and complete list of QLE’s that apply to your particular circumstance.*