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Specific changes that happen in your life may allow you to become eligible for certain health benefits. Identify the type of Qualifying Event (QE) that you may have encountered and to see if you are able to modify your health insurance coverage outside the open enrollment period.

  1. Gains A Dependent or Becomes A Dependent Through Birth or Adoption
  2. Gains A Dependent Or Becomes A Dependent Through Marriage or Domestic Partnership
  3. The Dependant Is Mandated To Be Covered Pursuant To A Valid State or Federal Court Order
  4. The Applicant or Dependent Lost Minimum Essential Coverage Due to Termination, or Change, In Employment Status or Reduction in Hours of Individual Providing Coverage to the Dependent
  5. The Applicant or Dependent Lost Minimum Essential Coverage Due to Cessation of An Employer’s Contribution Toward An Employee or Dependent’s Coverage
  6. Death of the Person Through Whom the Applicant Was Covered As A Dependent
  7. Entitlement of Benefits of the Subscriber Under Title XVIII of the Social Security Act (Medicare), Resulting In Loss of Coverage to the Dependents
  8. Dependent Child’s Loss of Dependent Status Under the Applicable Requirements of the Health Plan Contract (Such As Reaching Age 26) 
  9. Legal Separation or Divorce (through whom the applicant was covered as a dependent) 
  10. Loss of Coverage Under the Access for Infants and Mother’s Program, or the Medicaid Program. Includes Medi-Cal and Medicaid Share of Costs Program
  11. Loss of HMO Coverage Benefits as the Individual  No Longer Resides, Lives, or Works, in the HMO Service Area 
  12. The Applicant Became A Permanent Resident of California During A Month Outside Of The Open Enrollment Period and/or Gains Access To New Health Benefit Plans As A Result Of A Permanent Move
  13. Return from Active Military Service
  14. Other Qualifying Events may apply, such as: 
  • Loss of minimum essential coverage
  • Release from incarceration
  • Loss of coverage due to Employer Chapter 11 activity
  • His or her health benefit plan substantially violated a material provision of the contract 
  • Advance Premium Tax Credit (APTC) or Cost Sharing eligibility change
  • Completion of covered services when contracting provider is no longer participating
  • Enrollment/non enrollment in QHP unintentional, inadvertent, or erroneous
  • DOES NOT include termination or loss due to failure to pay premiums on a timely basis (including COBRA premiums) or situations allowing for a rescission

If You Have One Of The Qualifying Events Listed Below, Then You Must Apply Directly Through CoveredCalifornia.com.

  • American Indian Status (may be entitled to monthly SEP)
  • New United States Citizen (citizenship newly obtained)
  • Foster Child Status (does not include adoption)
  • Other Exceptional Circumstance (circumstance must be validated by Covered California)


Each qualifying event, also requires you to provide proper documentation to verify that your qualifying event occurred within the past 60 days. If you have any questions about these qualifying events and the proper documentation needed, feel free to give us a call at 1-888-512-8878.


 

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