Signing up for health insurance is typically a once-a-year event that occurs during a period called open enrollment. If you miss it, you’re out of luck on getting health insurance or making changes to your coverage until the next open enrollment—unless you have a qualifying life event.
A Qualifying Life Event (QLE) is a change in your employees’ lives that allows them to enroll in your health plan or make changes to their coverage. Employees who experience a QLE are eligible for a special enrollment period, which is a window during which they can enroll or make changes to their health coverage, including adding a spouse or dependents to the plan.
What type of life changes are considered Qualifying Life Events?
Some of the most common examples of QLEs are:
Marriage, divorce, or legal separation
An employee who gets married can add their new spouse to the plan. Or, they can drop your plan if they’re being added to their new spouse’s plan instead. And an employee who loses coverage under an ex-spouse’s plan as a result of divorce or legal separation would be eligible for a special enrollment period during which they can sign up for a plan your company offers.
The birth or adoption of a child
Your employee will have a special enrollment period during which they can add their new child to their coverage. Coverage for a newborn or newly adopted child will be backdated to the date of birth or adoption.
Involuntary loss of coverage under another plan
For example, let’s say your employee is covered under a spouse’s plan. But then the spouse quits their job, and with that, loses their health insurance. In this case, your employee would have an opportunity to enroll in your health plan, assuming they meet the rest of the eligibility guidelines. And if you offer coverage for spouses, their spouse could also enroll.
But the critical caveat here is that the loss of coverage has to be involuntary. If your employee had coverage under an individual market plan and simply canceled it or stopped paying the premiums, they would not qualify for a special enrollment period.
Change in employment that leads to a gain or loss of health insurance coverage, or a change in eligibility for benefits
Eligibility for health insurance coverage typically depends on the number of hours an employee works, or their classification as a full-time employee, as opposed to a part-time or seasonal worker. So if an employee goes from being part-time to full-time, and becomes eligible for your health benefits because of that change, they’d have a special enrollment period at that point.
Another example here might be an employee who is eligible for benefits under your plan but enrolls in a plan at their second job. If they lose their eligibility for health insurance at their other job, they’d have a special enrollment period during which they could sign up for a plan you offer.
Aging out of coverage on a parent’s plan
The Affordable Care Act (ACA) allows young adults to remain on a parent’s health plan until age 26. If you have employees who are on their parents’ plans, they’ll lose that coverage when they turn 26. When that happens, they’ll have a special enrollment period assuming they’re otherwise eligible for your plan.
You can find a more comprehensive guide to QLEs from the Department of Labor.
How do I handle a qualifying life event?
Employees who experience a qualifying life event will need to show proof of their QLE in order to have a special enrollment period. The necessary proof varies depending on the QLE, but things like marriage certificates, birth certificates, and letters from insurers indicating an impending (or recent) loss of other coverage can all count as proof.
When employees notify you that they’ve experienced, or are about to experience, a QLE, you may need to help them make sense of their special enrollment period. Here are some common questions they may have:
- What QLE documentation do they need to submit, and where should they send it? [The details will depend on your plan, so chat with your broker for guidance.]
- What’s the deadline for enrolling or making changes to their coverage during the special enrollment period? [Special enrollment periods are required to last at least 30 days (or 60 days in certain circumstances), though you can choose to make it longer if your insurance carrier approves.]
- When will the enrollment or plan changes take effect? [It depends on the qualifying life event. In most cases, the effective date will be the first of the month after the employee submits their enrollment or plan change request. If the QLE is a birth or adoption, then coverage will be backdated to the birth or adoption date.]
- When will they see payroll deductions for health insurance premiums? [Typically, premiums are deducted the same month as when coverage is provided, but some employers deduct the premiums in advance so they can send that money along to the insurer. However your organization manages payroll deduction of premiums, make sure to communicate that to your employees and be consistent with how you treat all employees.]
What about QLEs in the individual insurance market?
While the questions your employees have about QLEs are likely related to the job-based coverage you offer them, you might also run into questions about QLEs in the individual market from those who need to buy their own health insurance.
There’s a lot of overlap in the QLE rules for group and individual market plans, but one of the key differences is that special enrollment periods tend to last longer for people who are buying their own coverage. Special enrollment periods in the individual market last for 60 days after the QLE. And if the QLE is due to a loss of coverage, the special enrollment period also runs for 60 days before the loss of coverage so your employee can have a seamless transition to their new plan.Updated August 15, 2018
This article provides general information and shouldn’t be construed as legal, benefits, or HR advice. Benefits and insurance regulations may change over time and may vary by location and employer size. So, please consult a licensed broker or appropriately certified expert for advice specific to your business’s benefits options.