Don’t Get Stuck: What Really Counts as a Qualifying Life Event for Health Insurance
Something important came up this week, and it’s something a lot of people get wrong—what actually counts as a qualifying life event when it comes to health insurance.
A woman recently called me in a panic. She has a Marketplace health plan and was just diagnosed with a serious illness. The specialist she needs to see is in Dallas, but she lives in Austin—and her current plan doesn’t cover that doctor. The clinic told her she could switch plans because of her new diagnosis. Unfortunately, that’s not true.
Let’s break it down.
Getting Sick Is Not a Qualifying Event
We get it—you’ve got a new diagnosis and need better coverage. But here’s the truth:
➡️ Getting diagnosed with a critical illness is not a qualifying life event.
➡️ You cannot switch insurance plans outside of Open Enrollment because of a new health condition.
➡️ Clinics should not be giving insurance advice unless they are licensed to do so—especially if the information is wrong.
What Is a Qualifying Life Event?
To make changes to your Marketplace plan outside of Open Enrollment (Nov 1 – Dec 15), you must meet two conditions:
- You already have coverage.
- You’ve experienced one of these life changes within the last 60 days:
- You moved to a new zip code
- You got married or divorced
- You had a baby or adopted a child
- Someone on your policy passed away
- You lost other health coverage (employer, Medicaid, etc.)
You only have 60 days from the date of the event to make changes. After that, you’ll need to wait until Open Enrollment.
What About Private Plans?
Some off-market (private) plans still require a qualifying event to enroll, even outside the Marketplace. Losing coverage is typically the only exception they’ll allow.
One Possible Workaround…
In the case of the caller, I asked, “Are you planning to move to Dallas?” Because relocating is a qualifying event. If she truly moves, she can switch to a plan that covers the specialist she needs.
But for most people, the answer is: sit tight and wait for Open Enrollment. And that’s incredibly frustrating when your health can’t wait.
Final Thoughts:
Health insurance rules can be confusing—but the consequences of misunderstanding them are serious. Don’t rely on hearsay from a doctor’s office. Talk to someone who knows this stuff inside and out.
✅ If you have questions or think you qualify for a special enrollment period, schedule a free consult today.
