Small Group: Special Enrollment Quick Reference Chart

Life-Changing Qualifying Event (QE) – Mini-Open Enrollment

Any of the following events would allow the subscriber to change plans and/or add themselves or other family members with the effective dates as listed.

Life-Changing Qualifying Event (QE)
Qualifying Event	Effective Date Determination	Documentation
Newborn	Date of event	No documentation, but DOB must be on application
Adoption**	Date of event	Court documentation showing date when court order effective
Marriage / Domestic partnership	First of the month following date application is received	-
Legal guardianship / Court order dependent	Date of event	Court documentation showing date when court order effective

** Must be routed to case coordinator

Loss of minimum essential coverage

Includes (but are not limited to) any of the following events which resulted in a loss of minimum essential coverage, NOT INCLUDING voluntary termination, failure to pay premiums or situations allowing rescission.

Effective date determination

Oregon: Up to 30 days AFTER loss:

First of the month following date application is received

Washington: Up to 60 days AFTER loss:

First of the month following date application is received

Loss of minimum essential coverage
Qualifying Event	Documentation
Loss of coverage due to termination of employment or reduction of hours	One of the following: PCC* Front and back of previous carrier ID card Confirmation of work-hour reduction including termination from employer (must be on employer letterhead and signed by employer management)
Loss of coverage due to death of a covered employee	One of the following: PCC* Front and back of previous carrier ID card
Loss of coverage due to covered employee became entitled to benefits under Medicare	One of the following: PCC* Front and back of previous carrier ID card Eligibility document
Loss of coverage due to divorce or legal separation	One of the following: PCC* Front and back of previous carrier ID card
Loss of coverage due to maximum age dependent	One of the following: PCC* Front and back of previous carrier ID card Max age letter from previous carrier

Management review

These QEs require Health Net Management review and approval
Qualifying Event	Effective date determination	Documentation
The qualified individual's, or his or her dependent's, enrollment or non-enrollment in a health plan is unintentional, inadvertent or erroneous and is the result of the error, misrepresentation or inaction of an officer, employee or agent of the health plan or its instrumentalities as evaluated and determined by the health plan.	Management review and approval	Letter from applicant supporting the qualifying event
The health plan in which the enrollee, or his or her dependent, is enrolled substantially violated a material provision of its contract.	Management review and approval	Letter from applicant supporting the qualifying event

* Abbreviations:

EOM – End of month
PCC – Prior Coverage Certificate

SEP submission time frame
SEP	Time Frame
All SEPs except loss of coverage	30 days after event
Loss of coverage only	30 days before date of event 30 days after date of event

The default processing date for SBG is based on the qualifying event, including when enrollment would thus be retrospective. With the exception of birth or adoption, in the case that there is an appeal or grievance case, or threat of one, please permit an effective date of "first of the month following the date the enrollment form is received." This later date still aligns with regulatory time frames, even though the earlier, default date is compliant and to the benefit of the member in most cases.