California Health Insurance Special Enrollment-35 Qualifying Events

In California, we have California health insurance special enrollment options available for all residents.

Open enrollment is standard for any individual who is applying for health insurance. It usually begins in November for health insurance coverage so that the coverage will start in January.

However, situations can change which affects your health insurance coverage outside of this open enrollment period. Therefore there are ways to enroll in a health insurance plan outside of open enrollment to safeguard against unavoidable lapses.

Qualifying Events Determine Your Eligibility for Special Enrollment

“Qualifying Events” (the insurance term for changes in life circumstances) permit you to obtain or update your California health insurance special enrollment health insurance. As a result, if you have a major change in your life circumstances you may qualify for special enrollment!

A Qualifying Event allows you to apply for health insurance “outside” of the time period required for open enrollment. This is known as a “Special Enrollment.”

Abrams Insurance Solutions provides you with a list to help you determine if your new situation is a “Qualifying Event” .

If you do not appear to be covered under the following list – Do Not Assume You Do Not Qualify!

This list is not all inclusive and special circumstances are also considered. So don’t get discouraged if your unique circumstance is not on the list.

List of Qualifying Events for California Health Insurance Special Enrollment

The qualifying events for California health insurance special enrollment qualifying events include:

Losing or Soon To Lose Health Coverage

• Loss of Medi-Cal coverage
• Loss of employer sponsored coverage
• No longer eligible for student health coverage
• Cobra coverage is exhausted

Age Qualifications

• You turn 19 years old and are no longer eligible for a child-only plan.
• You turn 26 years old and are no longer eligible for a family plan.

Income Changes

Your income changes so much that you just become either newly eligible or drastically ineligible to apply for health insurance.

Change in California Residency

This includes California residents who:

• Move to California from out of state, or
• Move within California and now have access to at least one new California health plan.

Incarceration

• Individuals who are just recently released from jail or prison.

Having a Child or Adopting a Child

This also includes individuals who are taking a child into foster care; placing a child in adoption, or placing a child into a foster home.

Getting Married or Entering into a Domestic Partnership

One or both members can use special enrollment to apply for coverage.

New Citizenship or Lawful Presence

This means if you just became a new American citizen, or a national, or become a permanent legal resident, you may apply for coverage.

Federally Recognized American or Alaska Native

Any member of a federally recognized Indian tribe qualifies.

Returned from Active Military Service

This applies if you lost coverage after leaving active duty, reserve duty, and includes California National Guard.

Other California Health Insurance Special Enrollment Qualifying Life Events

• You become newly eligible or ineligible for tax credits or cost-sharing reductions.
• Misconduct or Misinformation During Enrollment – Where any authorized agent or representative enrolls you in a plan that you did not want to enroll; failed to enroll you in any plan, or failed to calculate eligible premium assistance..
• Become Eligible for COBRA coverage because of loss of employer-sponsored insurance.
• Misrepresentation or Erroneous Enrollment – Due to incorrect eligibility determination.
• The health plan you applied for failed to receive your information due to technical issues.
• Error occurred while processing your immigration documents that caused incorrect eligibility.
• Incorrect plan data was displayed – This includes errors on premiums, benefits or copay/deductibles were displayed, incorrectly displayed plans, or a family was not able to enroll together in a single plan.

• Your health plan violated its contract.  

• Exceptional circumstances occurred in choosing a plan deadline because of a natural disaster or medical emergency.
• You receive a certificate of exemption for hardship from Health and Human Services. You lose eligibility for the hardship exemption outside of an open enrollment period.
• You and your dependents are victims of domestic abuse or spousal abandonment.
• A court order requires you to provide health insurance for a child who was been determined ineligible for Medi-Cal and CHIP. This applies even though you do not expect to claim the child as a tax dependent.
• You are a member of AmeriCorps/VISTA/National Civilian Community Corps such as if you just entered or ended service outside of open enrollment.
• You have a “grandfathered” health insurance plan outside of California. You want to switch to a California health insurance plan instead.
• Your provider left the health plan network while you were receiving care for one of the following conditions:
  • Pregnancy.
  • Terminal illness.
  • An acute or chronic condition.
  • The care of a newborn child up to 36 months.
  • A surgery or other procedure will occur within 180 days of the termination or start date.

IMPORTANT NOTE: This list is NOT ALL-INCLUSIVE. There is also a section on application forms which include “NONE OF THE ABOVE”. Apply under this category when none of the above fit your situation.  Consideration of “None of the Above” works on a “CASE BY CASE BASIS.”

Qualifying Event Time Restrictions

Those who qualify for special enrollment may have to do so within a certain time frame such as 60 days. The time limitation begins from the date when the qualifying life event occurs. So don’t put this off!

This time period includes:

• Those who need to enroll in a California health insurance plan, or
• Those who need to change their existing California health insurance plan.

If you miss this time limitation period and have not applied for health coverage, you may have to wait until the next open enrollment period.

Plan Ahead to Avoid Gaps in Coverage

To avoid gaps in health coverage, you should plan ahead. The start date depends on the date of enrollment.

If you enroll by the 15th day of the month, the coverage usually starts on the first day of the next month.

If you enroll after the 15th day of the month, coverage will begin on the first day of the second month.

As a rule, it’s smart to plan your new coverage to avoid coverage gaps as much as possible.

There are some exceptions to the start date which may apply.

Find Out Which Special Enrollment Options Apply to You

If you have any questions, concerns or need advice about California health insurance special enrollment qualifying events, CLICK HERE to see what you will qualify for.