Qualifying Life Event Quick Reference Guide

October 25, 2022

How Do I Qualify?

While you are generally only allowed to change your benefits elections during the open enrollment period each year, certain life events provide an exception. Those life events allow you to change your benefits elections in the middle of the plan year if certain requirements are met. Qualified life events depend on a specific plan’s terms, but some common examples can be found below:

  • Change in status (e.g., marital status, number of dependents and employment status)
  • Significant cost changes
  • Significant curtailment of coverage
  • Change in coverage under other employer’s plan
  • Addition or significant improvement of benefits package option
  • FMLA leaves of absence
  • COBRA qualifying events
  • HIPAA special enrollment events
  • Medicare or Medicaid entitlement

 

Qualifying Life Event Reference Chart

Change in Legal Marital Status Required Documentation
Marriage Marriage certificate
Divorce/annulment Divorce decree/court ruling for annulment
Legal separation Court order verifying legal separation
Death of spouse Death certificate
Change in Number of Dependents Required Documentation
Birth Birth certificate
Death Death certificate
Adoption/placement for adoption Court order for adoption/placement for adoption
Gain or Loss Eligibility for Other Group Coverage (HIPAA special enrollment) Required Documentation
Group health plan Documentation from plan or issuer regarding change in eligibility (with effective date)
Change in Employment Status of Employee or Spouse Required Documentation
Loss of employment Termination documents or unemployment application
Start of employment Employer documentation of employment start date
Change in worksite Employer documentation showing change and impact on eligibility
Leave of absence Employer documentation stating employee has commenced or returned from leave
Change in Place of Residence Required Documentation
Change in place of residence of the employee, spouse or dependent that affects HMO eligibility Documents indicating how change in residence affects employee eligibility
Entitlement to Medicare of Medicaid Required Documentation
Employee, spouse or dependent becomes covered under Medicare or Medicaid, or loses eligibility for his or her Medicare or Medicaid coverage (including coverage under a state Children’s Health Insurance Program or CHIP) Government verification that coverage was gained or lost
Changes in Coverage Required Documentation
Significant cost increases N/A
Significant curtailment of coverage N/A
Addition or significant improvement of benefits package option N/A
Change in coverage under other employer plan Documentation from employer showing change in coverage
Loss of health coverage sponsored by governmental or educational institution Government verification of loss of eligibility
Other Required Documentation
Change of custody, judgment, court order or decree requiring health coverage Court documentation, including qualified medical child support order (QMCSO)
COBRA qualifying event N/A
FMLA leave N/A
Eligibility for premium assistance subsidy through a Medicaid plan or CHIP Government verification of eligibility for subsidy (with effective date)
Exchange enrollment Employee representation regarding enrollment in a plan under an exchange
Reduction in hours of service to less than 30 hours without loss of eligibility N/A

 

How Can I Change My Elections Mid-year?

Outside of open enrollment, you typically cannot make midyear benefit changes unless you experience a qualified life event. To change your elections midyear:

  • You must experience a midyear election change event recognized by the IRS.
  • The cafeteria plan must permit midyear election changes for that event.
  • Your requested change must be consistent with the midyear election change event.

If you believe you’ve experienced a qualifying life event, contact your HR manager. He or she will help you determine if you’ve experienced a qualifying life event or your plan allows for a midyear benefits change.

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