What is Considered a Qualifying Life Event and When Can Employees Change Coverage Mid-Year?
As a business owner, you’ve probably had employees ask, “Can I add my spouse now?” or “I just found out I’m pregnant, can I switch my plan?”
While you want to help your team however you can, health insurance rules are strict about when employees can make changes. Outside of your company’s annual open enrollment period, employees can only make changes to their benefits if they experience what’s known as a Qualifying Life Event (QLE).
Let’s break down what that means and what you, as an employer, need to know.
A Qualifying Life Event is a certain set of major life events that can trigger a special enrollment period for an employee. A QLE allows the employee to make changes to their benefit elections outside of Open Enrollment.
Some of the most frequently experienced QLE’s are:
Marriage or Divorce: This life event gives employees the chance to add or remove a spouse from their plan or elect a plan themself if they are removed from their spouse’s plan.
Birth or Adoption: Adding a new child to their family means your employee may need to add the new child to their benefits as well.
Loss of Other Coverage: If an employee’s spouse loses their job, it may also mean the employee is losing their coverage elsewhere. This life event allows them the opportunity to elect coverage that may have previously been waived through the group plans you offer.
Change in Employment Status: A move from part-time status to full-time status or vice versa means that an employee is now gaining eligibility or potentially losing eligibility to be enrolled in coverage.
Death of a Dependent or Spouse: A death in an employee’s immediate family can mean they may need to remove someone as a dependent or can mean they are losing their coverage and need to elect it through your group plans for the first time.
Significant Change in Premium Assistance: Sometimes employees can lose coverage for things like Medicaid or CHIP coverage. This is a type of loss of coverage and will allow them the opportunity to enroll in your benefits mid-year.
In cases like the above, timing is crucial. Employees usually have 30 days from the date of the qualifying event to submit their request and any required documentation (like a marriage certificate or proof of loss of coverage) to add or remove coverage.
If they miss this window, they’ll need to wait until your next open enrollment period to make changes — even if the situation feels urgent.
To avoid confusion or disgruntled employees, it is strongly recommended that you have a clearly communicated policy in place to deal with Qualifying Life Events. Your broker (that’s us!) should also assist in reminding employees during each Open Enrollment that if they do not make changes, they will not be able to until next Open Enrollment without a QLE.
These rules aren’t about being rigid — they exist to keep group plans fair and compliant. By setting clear expectations with your employees and partnering with a broker who understands the regulations, you’ll save time, reduce confusion, and keep everyone covered properly.
If you ever have an employee ask to make a change mid-year and you’re unsure whether it qualifies, reach out to us — we are here to help you navigate the situation and make sure it’s handled correctly.