Qualifying events
for the Off-Exchange Health Coverage
special enrollment period
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Checklist
Effective 01/01/2016
An individual who lives or resides in the service area and
is a California resident may apply for coverage due to a
qualifying event (QE).
This is referred to as a special enrollment period (SEP).
Documentation supporting eligibility under one of the
QEs listed below is required and must be submitted to
Blue Shield at the time of application.
Important: To be considered eligible in most cases, your
application for coverage due to a QE must occur within
60 days of the QE. Important note: An eligible individual or
dependent who experiences a loss of minimum essential
coverage (MEC), has 60 days prior to and 60 days following
the loss of coverage to enroll.*
The specific QE may apply to your entire family, or only to
the person affected. For example, if you had a newborn
child, you could enroll the child as an individual effective
on the child’s date of birth, or you could enroll your entire
family effective on the newborn’s date of birth.
Please be aware that the effective date differs based on
the QE. An SEP applies to new contracts and additions to
existing contracts due to a QE.
Gains a dependent or becomes
a dependent through birth,
foster care, or adoption.
Effective date: The date of birth or the date
the parent(s) have control of the health
care of the child being fostered or placed
for adoption (most times prior to the
adoption being final). You may also opt
for an effective date the first of the month
after the qualifying event.
BIRTH
 Birth certificate of the child (Hospital,
county, or government issued only)
ADOPTION &/or Placement for Adoption:
 Medical Authorization Form
 Evidence of the enrollee’s right to control
the health care of the child
 Relinquishment Form
Gains a dependent or becomes
a dependent through marriage
or domestic partnership.
Effective date: The first day of the month
after Blue Shield receives your request for
enrollment. For example, an application
received February 20 would have a
coverage effective date of March 1.
 Marriage certificate
 Partnership agreement
Qualifying events
for the Off-Exchange Health Coverage
special enrollment period
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Your dependent is mandated to
be covered pursuant to a valid
state or federal court order.
Effective date: If the request is postmarked
or received between the first and 15th of the
month, coverage will be effective the first day
of the next month. If the request is postmarked
or received between the 16th and the end of
the month, coverage will be effective the first
day of the second following month.
 Qualified Medical Child Support Order
(QMCSO)
 Valid state or federal court order
that dependent is mandated to be
covered
You or your dependent lost
minimum essential coverage
due to termination, or change in
employment status, or a reduction
in hours of the individual providing
coverage to the dependent.
Effective date: The first day of the month
after Blue Shield receives your application
for enrollment. For example, an application
received February 20 would have a
coverage effective date of March 1.
 COBRA, FMLA, or Cal-COBRA Election Form
 Coverage cancellation notice, Model
Notice, or Certificate of Creditable
Coverage
 Letter from employer on business
letterhead confirming loss of coverage or
reduction of hours of employment to less
than the number of hours required for
eligibility
Important! Qualifies under loss of minimum essential
coverage (MEC) criteria. This means the request
for coverage may be submitted up to 60 days prior
to and up to 60 days following the actual loss of
coverage effective date.
You or your dependent lost minimum
essential coverage due to cessation
of an employer’s contribution toward
your coverage which is not COBRA.
Effective date: The first day of the month
after Blue Shield receives your application.
For example, an application received
February 20 would have a coverage
effective date of March 1.
 COBRA, FMLA, or Cal-COBRA Election Form
 Coverage cancellation notice, Model
Notice, or Certificate of Creditable
Coverage
 Letter from employer on business letterhead
confirming loss of coverage which is not
COBRA
Important! Qualifies under loss of minimum essential
coverage (MEC) criteria. This means the request
for coverage may be submitted up to 60 days prior
to and up to 60 days following the actual loss of
coverage effective date.
Qualifying events
for the Off-Exchange Health Coverage
special enrollment period
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Death of the person through whom
you or your child were covered as
a dependent.
Effective date: The first day of the month
after Blue Shield receives your application.
For example, an application received
February 20 would have a coverage
effective date of March 1.
 Certified death certificate (facsimile OK)
 COBRA, FMLA, or Cal-COBRA Election Form
 Letter from employer on business
letterhead confirming loss of coverage
 Obituary (newspaper copy &/or
mortuary notice OK)
Entitlement of benefits under
Title XVIII of the Social Security
Act (Medicare), resulting in a
loss of coverage.
Effective date: The first day of the month
after Blue Shield receives your application.
For example, an application received
February 20 would have a coverage
effective date of March 1.
 Copy of Medicare card
 Approval letter of entitlement from
Social Security Office
And one of the following:
 COBRA, FMLA, or Cal-Cobra Election form
 Coverage cancel notice
 Letter from employer on business letterhead
confirming loss of coverage
Important! Qualifies under loss of minimum essential
coverage (MEC) criteria. This means the request
for coverage may be submitted up to 60 days prior
to and up to 60 days following the actual loss of
coverage effective date.
Your dependent child’s loss of
dependent status under the
applicable requirements of the
health plan contract (such as
reaching age 26).
Effective date: The first day of the month
after Blue Shield receives your application.
For example, an application received
February 20 would have a coverage
effective date of March 1.
 Letter from employer on business
letterhead confirming loss of coverage
 Coverage cancellation notice, Model
Notice, or Certificate of Creditable
Coverage
 Copy of letter from the carrier
explaining reason for dependent
cancellation
Important! Qualifies under loss of minimum essential
coverage (MEC) criteria. This means the request
for coverage may be submitted up to 60 days prior
to and up to 60 days following the actual loss of
coverage effective date.
Legal separation, divorce, or dissolution of domestic partnership
Qualifying events
for the Off-Exchange Health Coverage
special enrollment period
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through whom you were covered
as a dependent.
Effective date: The first day of the month
after Blue Shield receives your application.
For example, an application received
February 20 would have a coverage
effective date of March 1.
 COBRA, FMLA, or Cal-COBRA Election Form
 Coverage cancellation notice, Model
Notice, or Certificate of Creditable
Coverage
 Letter from employer on business
letterhead confirming loss of coverage
and one of the following:
 Divorce decree
 Notice of Termination of Domestic Partnership
(notarized)
 Other documentation supporting
divorce or dissolution of domestic
partnership
Important! Qualifies under loss of minimum essential
coverage (MEC) criteria. This means the request
for coverage may be submitted up to 60 days prior
to and up to 60 days following the actual loss of
coverage effective date.
Loss of coverage under the Access
for Infants and Mothers Program
or the Medicaid Program. Includes
Medi-Cal, Medicaid share of costs,
pregnancy-related coverage,
and medically-needy programs
or other government-sponsored
healthcare programs.
Effective date: The first day of the month
after Blue Shield receives your application.
For example, an application received
February 20 would have a coverage
effective date of March 1.
 Notification of loss of Children’s Health
Insurance Program or Medicaid coverage
from state program
Important! Qualifies under loss of minimum essential
coverage (MEC) criteria. This means the request
for coverage may be submitted up to 60 days prior
to and up to 60 days following the actual loss of
coverage effective date.
Loss of HMO coverage benefits
because you no longer reside, live,
or work in the HMO service area.
Effective date: The first day of the month
after Blue Shield receives your application.
For example, an application received
February 20 would have a coverage
effective date of March 1.
 Coverage cancellation notice, Model
Notice, or Certificate of Creditable
Coverage
and at least one of the following:
 Current utility billing statement confirming the
California address
 Lease or rental agreement
 Monthly mortgage statement
Monthly mortgage statement
Important! Qualifies under loss of minimum essential
coverage (MEC) criteria. This means the request
for coverage may be submitted up to 60 days prior
to and up to 60 days following the actual loss of
coverage effective date.
Qualifying events
for the Off-Exchange Health Coverage
special enrollment period
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You became a permanent resident
of California during a month outside
of the open enrollment period
and/or gained access to Qualified
Health Plans as a result of a
permanent move.
Effective date: If the request is postmarked
or received between the first and 15th of
the month, coverage will be effective the
first day of the next month. If the request
is postmarked or received between the
16th and the end of the month, coverage
will be effective the first day of the second
following month.
INFANTS & DEPENDENT CHILDREN (applying solo):
 Birth certificate of the child (hospital,
county, or government issued only) OR
supportive documentation confirming
the adoption or legal guardian status (as
applicable)
SCHOOL-AGED CHILDREN (applying solo):
 School enrollment record from the former
state
 California school enrollment record
(school-aged child)
ADULT APPLICANTS & FAMILIES:
 Verification of recent address
change, such as a utility billing
statement, rental agreement, or
mortgage statement from the
previous residence
Additionally, if moving from another country, please
submit one of the following
 Copy of Visa/passport information page and
the date stamped page
 Boarding pass showing name and entry date
into the United States
and at least one of the following:
 Current utility billing statement
confirming the California address
 Lease or rental agreement
 Monthly mortgage statement
Return from active military service.
Effective date: If the request is postmarked
or received between the first and 15th of
the month, coverage will be effective the
first day of the next month. If the request
is postmarked or received between the
16th and the end of the month, coverage
will be effective the first day of the second
following month.
 Certificate of Release or
Discharge from Active Duty
Qualifying events
for the Off-Exchange Health Coverage
special enrollment period
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Other qualifying events may apply,
such as:
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• Loss of minimum essential coverage*
• Release from incarceration
• Loss of coverage due to employer Chapter 11
activity from which the covered employee retired
• His or her health benefit plan substantially
violated a material provision of the contract
• Advanced Premium Tax Credit (APTC) or
cost-sharing eligibility change
• Completion of covered services when
contracting provider is no longer participating
• Enrollment/non-enrollment in a qualified
health plan was unintentional, inadvertent,
or erroneous resulting from the error,
misrepresentation, or inaction of the Exchange
or the Department of Health and Human
Services, or non-enrollment/not receiving
advanced premium tax credits or cost sharing
reduction as a result of a non-Exchange entity
providing enrollment assistance/activities (both
as determined by the Exchange)
Qualifying events that must be
referred to Covered California:
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• American Indian status (may be entitled
to a monthly special enrollment period)
• New United States citizen (citizenship
newly obtained)
• Other exceptional circumstance (circumstance
must be validated by Covered California)
Qualifying events
for the Off-Exchange Health Coverage
special enrollment period
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Blue Shield of California is an independent member of the Blue Shield Association A47614 (12/14)
* Loss of Minimum Essential Coverage (MEC) can be a result of:
a. Legal separation†
b. Divorce† or dissolution of domestic partnership
c. Cessation of dependent status (such as attaining the maximum age to be eligible as a dependent
child under the plan)†
d. Death of an employee†
e. Termination of employment†
f. Reduction in the number of hours of employment†
g. A covered employee becoming entitled to Medicare and a dependent loses coverage†
h. A Proceeding under Chapter 11 with respect to the employer from whose employment the covered
employee retired at any time†
Any loss of eligibility for coverage through Medicare, Medi-Cal, including loss of pregnancy-related
coverage1 and medically-needy coverage,2 or other government-sponsored health coverage.
Loss of Minimum Essential Coverage does NOT include failure to pay premiums or rescission of prior coverage
Per the federal government and Covered California, a loss of minimum essential coverage (MEC) allows
applicants to submit a request for coverage up to 60 days before and after the loss of coverage effective
date. This is intended to avoid a coverage gap when switching to the new plan.
† Existing ERISA qualifying events, required by federal regulations. 147.104(b)(3), referencing Section 603 of ERISA.
1 If loss of Medi-Cal coverage for pregnancy-related services, the date of the loss of coverage is the last day the consumer would have pregnancy-related coverage.
2 If loss of Medi-Cal coverage for medically needy services, the date of the loss of coverage is the last day the consumer would have medically needy coverage.
Qualifying events for the Off-Exchange Health Coverage special enrollment period

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