Qualifying Events

Qualifying Events Special Enrollment

Most of the year, benefits can only be changed during your company’s open enrollment. Outside of that window, changes (adding or dropping coverage) are allowed only if there’s a qualifying event (QE). This page explains the basics for both employees and HR, so everyone knows when a mid-year change is allowed and what proof is needed.

The 30-Day Rule

By federal requirement, mid-year changes must be completed within 30 days of the qualifying event (or the plan’s loss-of-coverage date). “Completed” means your elections are submitted and the required documentation is received by the deadline. Don’t wait until day 30. This applies to both joining and leaving the plan mid-year.

Common Qualifying Events (examples)

• Loss of employment (involuntary) or reduction of hours causing loss of eligibility
• Marriage or divorce / legal separation
• Birth, adoption, or placement for adoption
• Death of the employee
• Dependent status change (e.g., a child ages out)
• Loss of other coverage (e.g., losing Medicaid/CHIP, Medicare, a student plan, or another employer plan for the employee or spouse)
• Gain of other coverage (e.g., qualifying for and enrolling in Medicaid/CHIP, Medicare, a student plan, or another employer plan for the employee or spouse)
• Move out of the plan’s service area (when it makes the current plan unavailable)

What Does Not Count

• A spouse voluntarily drops you (or doesn’t enroll you) during their open enrollment — that’s not an involuntary loss for you
• Changing your mind or preferring a different plan mid-year
• Missing your employer’s open enrollment window
• Provider leaving a network, or routine plan updates that don’t trigger a QE
• Enrolling in, or just not paying for, an individual plan

Proof You’ll Need

Keep it simple and complete. Most carriers want a brief letter (or official notice) that includes: (1) everyone’s full name who is affected, (2) the event (e.g., loss of employment), and (3) the specific coverage termination date for each person. Acceptable proof can come from an employer HR letter, COBRA notice, Medicaid/Medicare determination, or a spouse’s employer letter.

HR & Employees: Use our sample as a template. Employees may send it to their (or their spouse’s) employer to request the correct verification. The most common mistakes we see are missing dependents’ names and no explicit coverage end date.

What To Do Now

1. Notify HR immediately. The 30-day clock is strict.
2. Gather proof. Use the template above or an official notice (Medicaid/Medicare, prior employer, spouse’s employer, etc.).
3. Complete elections. Submit your choices and documentation within 30 days.
4. Keep a copy. Save your letter/notice and confirmation for your records.

Questions? Call 443.461.4015 x3 or schedule a call.