Small Group Plans
Special Enrollment Quick Reference Chart
Life-Changing Qualifying Event (QE) – Mini-Open Enrollment
Any of the following events would allow the subscriber to change plans and/or add him or herself, or his/her dependents, with the effective dates as listed.
| Qualifying event | Effective date determination | Documentation |
|---|---|---|
| Newborn | Date of event |
Birth certificate. |
| Adoption or placement for adoption (must be routed to case coordinator) |
Court documentation showing date when court order effective. | |
| Assumption of a parent-child relationship (must be routed to case coordinator) |
Date of event | Court documentation showing date when court order effective. |
| Marriage | First of the month following date application
is received. |
Marriage certificate |
| Domestic partnership |
|
Loss of minimum essential coverage
Includes (but is not limited to) any of the following events, which resulted in a loss of minimum essential coverage, NOT INCLUDING voluntary termination, failure to pay premiums or situations allowing rescission for fraud or intentional misrepresentation of material fact.
| Qualifying event | Effective date determination | Documentation |
|---|---|---|
| Loss of coverage due to death of the covered employee. | Up to sixty (60) days AFTER date of qualifying event: First of the month following date application is received. | One of the following:
|
| Loss of coverage due to termination or reduction of hours, of the covered employee's employment. | One of the following:
|
|
| Loss of coverage due to divorce or legal separation of the covered employee from the employee's spouse. | One of the following:
|
|
| The enrollee loses a dependent or is no longer considered a dependent through divorce, legal separation or dissolution of domestic partnership as defined by state law in the state in which the divorce, legal separation or dissolution of domestic partnership occurs or if the enrollee or enrollee's dependent dies. | One of the following:
|
|
| The covered employee becoming entitled to benefits under Medicare. | Up to sixty (60) days AFTER date of qualifying event: First of the month following date application is received. | One of the following:
|
| A dependent child ceasing to be a dependent child under the generally applicable requirements of the plan. | One of the following:
|
|
| Loss of minimum essential coverage for any reason other than failure to pay premiums or situations allowing for a rescission for fraud or intentional misrepresentation of material fact. |
|
|
| Termination of employer contributions. | Notice from employer of contributions termination. | |
| Exhaustion of COBRA continuation coverage. | COBRA paperwork reflecting exhaustion of coverage. | |
| Loss of medically needy coverage under Medi-Cal (Medicaid). | Medicaid and/or Medi-Cal documentation. | |
| Loss of pregnancy-related coverage under Medicaid and/or Medi-Cal. | Medicaid and/or Medi-Cal documentation. | |
| Losing eligibility for coverage under a Medicaid plan under XIX of the Social Security Act or a state child health plan under XXI of the Social Security Act. | Medicaid documentation. | |
| Becoming eligible for assistance under a Medicaid plan or a state child health plan. | Medicaid documentation. |
Other Qualifying Events
| Qualifying event | Effective date determination | Documentation |
|---|---|---|
| The enrollee or enrollee's dependent's enrollment or non-enrollment in a health plan is unintentional, inadvertent, or erroneous and is the result of the error, misrepresentation, misconduct, or inaction of an officer, employee, a non-Exchange entity providing enrollment assistance or conducting enrollment activities, or agent of the Exchange or the Department of Health and Human Services, or its instrumentalities as evaluated and determin ed by the Exchange.1 | Management review and approval. |
|
| The health plan in which the enrollee or enrollee's dependent is enrolled in substantially violated a material provision of its contract.1 |
|
|
| The enrollee demonstrates to the Exchange that he or she did not enroll in a health benefit plan during the immediately preceding enrollment period available to the individual because he or she was misinformed that he or she was covered under minimum essential coverage. | Up to sixty (60) days AFTER date of qualifying event: First of the month following date application is received. |
|
| The enrollee is a member of the reserve forces of the United States military returning from active duty or a member of the California National Guard returning from active duty service under Title 32 of the United States Code. | Active duty discharge documentation | |
| Release from incarceration | Probation or parole release paperwork showing date of event. | |
| The enrollee is a victim of domestic abuse or spousal abandonment, including a dependent or unmarried victim within a household, and is enrolled in minimum essential coverage and seeks to enroll in coverage separate from the perpetrator of the abuse or abandonment; or is a dependent of a victim of domestic abuse or spousal abandonment, on the same application as the victim. | A signed written statement under penalty of perjury stating enrollee's name and names of the victims of domestic abuse who enrolled in coverage. | |
| The enrollee or enrollee's dependent applies for coverage through Covered CaliforniaTM during the annual open enrollment period or due to a qualifying event, is assessed by Covered California as potentially eligible for Medi-Cal, and is determined ineligible for Medi-Cal either after open enrollment has ended or more than 60 days after the qualifying event; or applies for coverage with Medi-Cal during the annual open enrollment period and is determined ineligible after open enrollment has ended. | Denial of eligibility letter from Covered California or Medi-Cal. | |
| The enrollee adequately demonstrates to Covered California that a material error related to plan benefits, service area or premium influenced his or her decision to purchase coverage through Covered California. | A signed written statement under penalty of perjury stating enrollee's name, name of the health plan, what error occurred, and the date on which the error occurred. | |
| The enrollee was receiving services under another health benefit plan, from a contracting provider who is no longer participating in that health plan, for any of the following conditions: (a) an acute or serious chronic condition, (b) a terminal illness, (c) a pregnancy, (d) care of a newborn between birth and 36 months, or (e) a surgery or other procedure that has been recommended and documented by the provider to occur within 180 days of the contract's termination date or within 180 days of the effective date of coverage for a newly covered member, and that provider is no longer participating in the health plan. |
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| If the enrollee or enrollee's dependent is Native American and enrolling in a qualified health plan or changing from one qualified health plan to another, one time per month.1 |
|
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| The enrollee or enrollee's dependent gains access to a new health plan as a result of a permanent move. | Up to sixty (60) days AFTER date of qualifying event: First of the month following date application is received. | Copy of acceptable proof of residency documents:
|
| SEP submission time frame | |
|---|---|
| All SEPs except loss of coverage |
60 days after event |
| Loss of coverage only | |
1These QEs require Health Net management review and approval.
Health Net of California, Inc. and Health Net Life Insurance Company are subsidiaries of Health Net, Inc. Health Net is a registered service mark of Health Net, Inc. All rights reserved.
