Triggering Events Signature Form BREAKING NEWS: More Step Triggering Events Released 5/2/2014
Click here to read more about Special Enrollment Periods for Complex Cases
• Renewal of a grandfathered or non-grandfathered individual major medical plan in 2014
• Return from active military duty
• Release from incarceration
• Gain of immigration status or citizenship
• Permanent move to a new state
Loss of minimum essential coverage due to
• Discontinuation of a current plan that does not meet health care reform requirements
• Legal separation
• Divorce
• Termination of domestic partnership or civil union*
• Change in full-time employment status
• Involuntary loss of employer-sponsored insurance
• Death of a parent or spouse
• Change in dependent status as a result of turning 26
Gaining or becoming a dependent due to
• Marriage
• Domestic partnership*
• Birth of child/children
• Adoption of child/children
• Placement for adoption of child/children
• Guardian/court-ordered dependent
Effective date rules
• Customers can apply 60 days prior to the life event date(electronically in most states, by paper in all states).
• Customers must apply no later than 60 days after their life event
• Effective dates of the 1st and 15th of the month will be available during the 60-day special enrollment period following the life event date, subject to the application submission date rules below. Additional effective date options may be available, beyond those shown on the online application (EASE). The Individual Enrollment Department will make available any additional effective date options.In the event of a renewal of a grandfathered or non-grandfathered plan:
• The qualified life event date is the renewal date
• Customers’ effective date can be as early as 30 days prior to the renewal date.All states, except Colorado
• Effective date is determined based on the application sign date and the life event date.
• The effective date will not be prior to the life event date.
• The effective date will either be the 1st or the 15th of the month. The next available effective date will be allowed, as long as it is after the application signed date and on or after the life event date. The effective date cannot be the same as the application signed date.
• The effective date will be the date requested on the application, if that date is available. However, an alternate date can be requested through the Individual Enrollment Department
Required documentation
Triggering event Requirements
Renewal of grandfathered or non-grandfathered plan • Completion of the following as part of the online or paper application
• Qualifying Life Event attestation (If completing a paper application, complete and attach Form 35020)
• Carrier for prior coverage
• Policy/Certificate number of prior coverage
• Type of coverage
• Termination date of prior coverage
Return from active military duty • Copy of discharge papers/certificate
Release from incarceration • Copy of documents showing release from incarceration
Gain of eligible immigration status or citizenship • Copy of document showing proof of immigrant status or change in status
Permanent move to a new state • Copy of rental agreement or Copy of utility bill from former address (gas, electric, cable,phone, sewer, water
Loss of minimum essential coverage due to:
• Completion of the following as part of the online or paper
application:
• Qualifying Life Event attestation (If completing a
paper application, complete and attach Form 35020)
• Carrier for prior coverage• Policy/Certificate number of
prior coverage
• Type of coverage
• Termination date of prior coverage
• Discontinuation of a current plan that does
not meet health care reform requirements
• Legal separation
• Divorce
• Termination of domestic partnership or civil
union(in applicable states)
• Change in full-time employment status
• Loss of employer-sponsored insurance
• Death of parent or spouse
• Change in dependent status as a result
of turning 26
• Completion of the following as part of the online or paper application:
• Qualifying Life Event attestation (If completing a paper application, complete and attach Form 35020)
• Carrier for prior coverage• Policy/Certificate number of prior coverage
• Type of coverage
• Termination date of prior coverage
Gaining or becoming a dependent due to:
• Marriage • Copy of signed marriage license or Copy of marriage certificate
• Domestic partnership(In applicable states) • Domestic partnership certificate or Affidavit of domestic partnership
• Birth of child/children • Copy of the birth certificate or Copy of birth verification or Copy of footprint certificate from the hospital
• Adoption of child/children • Copy of court order granting adoption or Adoption certificate
• Placement for adoption of child/children • Letter of placement for adoption or Copy of adoption placement agreement
• Guardian/court-ordered dependent • Copy of decree and order of appointment of guardianship of a minor or Letter of authority or guardianship from a
judge Last Available
