Open enrollment for 2014 individual and family plan coverage has ended; however, you can apply for and get health insurance coverage during the Special Enrollment period if you experience certain life events. See the table below for a list of the qualifying events.
To be eligible, you must complete your application for coverage within 60 days of the qualifying event or loss of coverage, whichever is later. If your application is not completed within this time period, it will expire and you will no longer be eligible for Special Enrollment. You must print and complete this Special Enrollment Period form and submit it along with your application.
|The birth, placement for adoption or adoption of the applicant for whom coverage is sought; for Qualified Health Plans (QHPs), also applies to children placed in foster care, legal wards or medical support orders||Copy of birth certificate
Copy of the adoption papers
Copy of foster care papers
Copy of medical support order
Copy of the court order appointing a guardian
|The loss of eligibility for Medicaid or a public program providing health benefits||Letter from Medicaid or other program indicating loss of eligibility.|
|A permanent change in residence, work, or living situation, where the prior health plan does not provide coverage in that person's new service area||Utility bills from your prior address and new address within
the last 90 days and a verification letter from your prior
|The loss of coverage as the result of dissolution of marriage or termination of a domestic partnership||Copy of divorce decree or annulment papers, a statement (including the date) the Domestic Partnership ended or a letter from the prior health plan|
|Marriage or entering into a domestic partnership, including eligibility as a dependent||Copy of marriage certificate, state registration, utility bill, lease or car title with both names clearly listed|
|Loss of minimum essential benefits, including loss of employer sponsored insurance coverage; except for voluntary termination, misrepresentation or fraud||Your COBRA offer letter or a letter from your employer listing each applicant that experienced a loss of coverage and reason for termination|
|Loss of coverage purchased on the Exchange, due to an error by the Exchange, the health plan, or Health and Human Services (HHS)||Letter from the Exchange, health plan or HHS indicating coverage was lost due to an error|
|If coverage is discontinued in a qualified health plan by the health benefit exchange pursuant to 45 C.F.R. 155.430 and the three month grace period for continuation of coverage has expired||Letter from the Exchange or health plan indicating coverage was discontinued by the Exchange and the three month grace period for continuation of coverage has expired|
|Exhaustion of COBRA coverage due to failure of the employer to remit premium||Letter from employer or COBRA administrator indicating loss was due to failure of the employer to remit premium|
The COBRA coverage period ends (usually after 18 months) or the individual has exceeded the lifetime limit in the plan and no other COBRA coverage is available
Note: Voluntary termination of COBRA is not a qualifying event. If you terminate or stop paying for your COBRA, you must wait for the next Open Enrollment Period to apply.
|Letter from employer or COBRA administrator indicating loss of COBRA coverage due to individual exhausting the COBRA period or exceeding the lifetime limit in the plan and that no other COBRA coverage is available|
|A situation in which a plan no longer offers benefits to the class of similarly situated individuals that includes the applicant||Letter from the prior health plan indicating loss of coverage due to not being in a class of similarly situated individuals|
|Loss of coverage as a dependent on a group plan due to age||Letter from employer or insurance health plan indicating loss of coverage due to age|
|If the person discontinues coverage under WSHIP||Letter from WSHIP indicating coverage has been discontinued|
This is a web site from CDA Insurance LLC. CDA Insurance LLC is not an insurance carrier, we are an agency that represents many companies offering products to the general public and also to medicare recipients. We do our best to assure that all information presented on our web site is current and accurate.
If you have current coverage and are applying for new coverage from a different company, do not cancel the existing coverage until your new policy has been issued.