Qualifying Events

The following are considered “Qualifying Events” to obtain individual health coverage.

1) Involuntary loss of Minimum Essential Coverage (loss of minimum essential coverage includes loss of eligibility of coverage as a result of legal separation, divorce, cessation of dependent status (such as attaining the maximum age to be eligible as a dependent child under the plan), death of an employee, termination of employment, reduction in the number of hours of employment. Loss of eligibility does not include a loss due to the failure of the employee or dependent to pay premiums on a timely basis or termination of coverage for cause (such as making a fraudulent claim or an intentional misrepresentation of a material fact in connection with the plan);

2) Gain a dependent or become a dependent through marriage, domestic partnership, birth, adoption, placement for adoption, or appointment of domestic partnership;

3) Mandated to be covered as a dependent pursuant to a valid state or federal court order;

4) Release from incarceration;

5) Health coverage issuer substantially violated material provision of health coverage contract;

6) Access to new health benefit plans due to permanent move;

7) Loss of services from contracting provider under another health benefit plan, as defined in Sections 10965 of the Insurance Code or 1399.845 of the Health and Safety Code, for a condition described in Health and Safety Code ยง 1373.96(c) (an acute condition, serious chronic condition, pregnancy, terminal illness, care of newborn between birth and 36 months of age, or performance of a surgery or other procedure that has been recommended and documented by the provider) and that provider is no longer participating in the health benefit plan;

8) Member of the Reserve Forces of the U.S. military returning from active duty or member of the California National Guard returning from active duty under Title 32 of the U.S. Code.

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