What Counts as a Qualifying Life Event? 

Life comes at you fast”—it’s an adage that HR, perhaps more than any other department, is familiar with. And when it comes to managing employee benefits, it rings especially true.
 

Whether your employees are walking down the aisle or expecting a new bundle of joy, chances are they aren’t thinking about their benefits in the heat of the moment. But these qualifying life events, or “QLEs” for short, give employees the rare opportunity to reevaluate and change their elections.
 

Below we’ll discuss why QLEs matter, what events are covered, and how much time employees have to take action.
 

Why QLEs Matter
 

 

If you’ve ever conducted an open enrollment, you already know full well that benefits elections stick with employees for the duration of the plan year. It’s the reason why establishing a communication strategy is so critical to executing a successful enrollment period. There likely isn’t a senior HR professional in the country who hasn’t been asked by an employee whether he or she can change elections midyear, or worst yet, right after the enrollment deadline.
 

“Redos” are a rarity in employee benefits—that is, unless you’ve just experienced a QLE.
 

Enter the Health Insurance Portability and Accountability Act of 1996 (HIPAA), which among other things, entitles certain individuals access to what the law calls a “special enrollment period.” Why? Having a child, for example, no doubt comes with a new set of coverage demands. Under federal law, qualifying individuals must be allowed to update their coverage choices and add or remove beneficiaries to adjust for those life changes.
 

What Qualifies?
 

 

We’ve mentioned marriage and childbirth—but there are several other events that qualify. Though individual carriers and policies can differ on the specifics (for example, allowing domestic partners to take part in QLEs is an employer/carrier decision), there are some situations that are federally enshrined and always considered QLEs. If you’re unsure whether an event qualifies, double-check with your benefits broker or your carrier’s policy documents.
 

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First, any change in marital status is covered, including divorce. Notably, in some cases you may not even have to be legally married to qualify. Civil unions and domestic partnerships are often considered in the same light as marriage, but specifics vary by employer, carrier, and jurisdiction. For example, the Illinois Religious Freedom Protection and Civil Union Act grants couples in civil unions the same rights as their married counterparts—meaning carriers in the state have to offer the same special enrollment rights to them, too.
 

As alluded to earlier, the birth of child is covered, as is adoption. Going further, taking on a foster child or becoming a legal guardian is almost always covered as well, depending on the carrier.
 

Those are all fairly obvious cases, but there are less apparent QLEs out there, including:

 

  • Turning 26 and aging out of a parent’s insurance (or having a dependent age out of yours)
  • Turning 65 and becoming eligible for Medicare
  • Employment status change from full-time to part-time, or vice versa
  • Relocating to a different state, if the state affects network access (relevant for HMOs or DMOs)
  • An individual's spouse has lost his or her coverage
  • Recently gaining U.S. citizenship

 

As you can tell, the list of QLEs is fairly comprehensive. To find them all in one spot, here’s a helpful list for your reference. Always consult with your broker or benefits carrier when you’re unsure of whether an employee’s life event actually qualifies.
 

Note that if an employee experiences a QLE, carriers will often ask for proof that it actually took place. You or an employee may be asked to provide a marriage certificate, birth certificate, or any other applicable documentation before any changes take effect.
 

In addition, remember that state insurance exchanges can, and often do, go beyond what federal law provides. In 2015, New York became the first state to make pregnancy—not just childbirth—a qualifying life event on its state healthcare exchange. A similar bill is being deliberated in Connecticut this year, and bipartisan support for the measure suggests we may even see broader action from Washington later this year.
 

How Much Time?
 

 

As mentioned earlier, communicating deadlines to your employees is key, especially since most employees only first learn about QLEs after they occur. Under federal law, you’ll have at least 30 days after the QLE transpired to make any election changes. Note that several carriers and the Health Insurance Marketplace give you up to 60 days.
 

To stay ahead of these tight timeline, get a pulse on what’s happening in the workplace—do you hear wedding bells? Are baby photos popping up on your company news feed? Great HR is proactive; reach out and make sure employees know their options before it’s too late.

 

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