Each QLE carries some fairly strict guidelines in order for it to qualify you for a special enrollment period.
- Lost my health insurance including Medi-Cal
- Permanently moved to/within California
- Had a baby
- Adopted a child
- Got married
- Entered into a domestic partnership
- Returned from active duty military service
- Released from incarceration
- Gained citizenship/lawful presence
- American Indian/Alaskan Native
- Other qualifying life events
- None of the above
Lost my health insurance including Medi-Cal
If you’ve lost or will soon lose Minimum Essential Coverage (MEC) health insurance, you may qualify for special enrollment. In order to qualify, you must not have lost your coverage voluntarily. That means, for example, you do not qualify if your coverage was canceled because you weren’t able to pay for it. However, if you had employer-sponsored coverage and lost your job, you probably lost your coverage as well. In this case, you would qualify and may enroll in a plan. Consumers (new and existing) who have an involuntary loss of MEC will have a unique 120-day special enrollment period in which they can apply – up to 60 days before and 60 days after the loss event date.
Another common example is someone who loses their Medi-Cal coverage. Perhaps you’ve been on Medi-Cal for a while, and then you receive a raise on your job or start working more hours. If your increased income pushes you above the threshold for Medi-Cal and it’s canceled, you would qualify for special enrollment.
- COBRA coverage expires (cannot be for non-payment)
- You don’t qualify for student health coverage anymore
- You don’t qualify for a family plan anymore because you turned 26
- You don’t qualify for a child-only plan anymore because you turned 19
Permanently moved to/within California
If you moved to California from another state in the last 60 days, you qualify for special enrollment.
If you moved within California, from one residence to another, you MAY qualify for special enrollment. In order for this to be the case, there must be at least one Covered CA plan available to you at your new address that was not available to you before.
Consumers with this type of life event are not required to have had prior coverage in order to qualify for special enrollment.
Had a baby
If you had a baby, adopted a child, or received a child into foster care in the last 60 days, your entire family qualifies for special enrollment. Also, you qualify for special enrollment if your child was placed for adoption or foster care.
If your qualifying event involves foster care you will need to select “adopted a child”
Adopted a child
If you adopted a child, had a baby, or received a child into foster care in the last 60 days, your entire family qualifies for special enrollment. Also, you qualify for special enrollment if your child was placed for adoption or foster care.
If your QLE involves foster care you will need to select “adopted a child”
If you got married in the last 60 days, you and your spouse qualify for special enrollment and may purchase a health plan.
Entered into a domestic partnership
If you entered into a legally recognized domestic partnership in the last 60 days, you and your partner qualify for special enrollment and may purchase a health plan.
Returned from active duty military service
If you’ve lost coverage in the last 60 days due to leaving active duty, reserve duty, or the California National Guard, you qualify for special enrollment and may purchase a health plan.
Released from incarceration (jail or prison)
If you were released from jail or prison in the last 60 days, you qualify for special enrollment and may purchase a health plan.
Gained citizenship/lawful presence
If you become a citizen, a national, or a permanent legal resident of the U.S. in the last 60 days, you qualify for special enrollment and may purchase a health plan.
American Indian/Alaska Native
If you are an American Indian/Alaska Native and are a member of a federally recognized tribe, you can enroll at any time throughout the year regardless of the enrollment period. You may also change health plans up to once a month.
Other qualifying life events
If none of the events listed above apply to you, you may be able to select “Other Qualifying Life Event” if:
- you currently have a Covered California plan and become eligible or ineligible for cost-sharing reductions or tax credits.
- when you applied, misconduct or misinformation occurred on the part of your authorized representative, or incorrect eligibility or plan information occurred during enrollment.
- your enrollment was affected by technical issues on Covered California’s website.
- your health plan violated its contract.
- you experienced a natural disaster or medical emergency near the open enrollment deadline.
- Health and Human Services issued you a certificate of exemption but you lost exemption outside of open enrollment.
- a child you’ve been ordered to provide insurance for is ineligible for Medi-Cal and CHIP, regardless of whether or not you plan to claim the child on your taxes.
- you entered or ended AmeriCorps/VISTA/National Civilian Community Corps outside of an open enrollment period.
- you’re currently on a “grandfathered” or “non-grandfathered” plan outside of Covered California, and your plan is set to renew outside of open enrollment, but you would like to switch to a Covered California plan instead.
- your provider left the network while you were being treated for any of the following:
- terminal illness
- an acute condition
- a serious chronic condition
- the care of a newborn between 0 and 36 months
- surgery or other procedure that will occur within 180 days of the termination or start date.
None of the above
If you do not have a QLE listed above, you can still apply to see if you qualify for Medi-Cal or the Medi-Cal Access Program (MCAP) for pregnant women based on your income and family size regardless of enrollments periods. Your application will be screened for eligibility in these programs no matter which qualifying event is selected.
Click here for a link to Covered CA's SEP Page.