A Qualifying Life Event (QLE) is a term used when an employee’s life changes so significantly that they’re allowed to enroll in a new health insurance plan or make changes to the current plan outside of the Open Enrollment period.

Employers and health insurance providers can face penalties and legal consequences if they fail to classify QLEs correctly, fail to correctly document or process information, or fail to inform employees of their rights.

Special Enrollment Period (SEP)

Health insurance providers typically only allow employees to enroll in a new plan or adjust their existing plan during a specific window each year, known as Open Enrollment. Open Enrollment dates can vary, but they usually occur between November and January.  

However, when an employee experiences a QLE outside the Open Enrollment period, they’re given a Special Enrollment Period (SEP). This allows them to make changes to the benefits or coverage of their health insurance plan in response to a significant life change. 

Employers have the responsibility to accommodate QLEs and ensure employees can make the necessary changes to their health insurance plan.

Types Of QLEs

QLEs are specific events defined by the Internal Revenue Service (IRS), such as:

Loss of health insurance

You may lose your current health insurance benefits or coverage for several reasons, including: 

  • You are turning 26 and losing coverage through a parent’s insurance plan
  • You are losing job-based insurance coverage. You will need to provide a workplace termination letter if this is the QLE. 
  • You are no longer eligible for Medicare, Medicaid, or the Children’s Health Insurance Program (CHIP)
  • You are losing health insurance coverage for any reason other than not paying the premiums

Household changes

There are a few household and family changes that qualify as QLE, such as:

  • Getting married, separated, or divorced. You will need to show court-filled divorce papers if using divorce as a QLE. 
  • Having a baby, adopting a child, or a foster care placement. You will need to show a birth certificate or adoption/foster papers if using this as a QLE. 
  • Experiencing the death of someone on your health insurance policy

Residence changes

You may have a QLE if there are specific changes to your residence, such as: 

  • Moving to a different state, county, city, or zip code
  • Moving into or out of a shelter or transitional housing tenancy
  • Moving to the US from a US territory or a foreign country

Eligibility changes

There are also some QLEs based on changes to your eligibility for health insurance coverage, including:

  • Changes to your income that affect your eligibility for Medicaid
  • Joining a federally recognized Native American tribe
  • Becoming a new US citizen and being eligible for Marketplace coverage
  • Beginning or ending service for the AmeriCorps VISTA
  • Being discharged from the US military
  • Being released from incarceration

What If I Miss The QLE Window?

Depending on your health insurance plan and provider, a QLE gives you a 30 to 60-day Special Enrollment Period (SEP) to make changes or sign up for new coverage.

If an employee fails to report their QLE or misses the SEP, they can no longer make changes to their plans until the next annual Open Enrollment period. Until the changes are made, an employee may not have appropriate coverage and may incur higher-than-necessary costs. 

Employers can help employees who have missed their QLE window by guiding them through the appeal process, assisting with COBRA enrollment, and providing documentation and guidance.