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Broker Health Care Reform Guide

Small Group Plans

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 him or herself, or his/her dependents, with the effective dates as listed.

Qualifying event Effective date determination Documentation
Newborn Date of event
Birth certificate.
Adoption or placement for adoption
(must be routed to case coordinator)
Court documentation showing date when court order effective.
Assumption of a parent-child relationship
(must be routed to case coordinator)
Date of event Court documentation showing date when court order effective.
Marriage First of the month following date application is received.
Marriage certificate
Domestic partnership
  • Declaration of domestic partnership.
  • Certificate of registered domestic partnership.

Loss of minimum essential coverage

Includes (but is 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 for fraud or intentional misrepresentation of material fact.

Qualifying event Effective date determination Documentation
Loss of coverage due to death of the covered employee. Up to sixty (60) days AFTER date of qualifying event: First of the month following date application is received. One of the following:
  • Prior coverage certificate.
  • Front and back of previous carrier's ID card
Loss of coverage due to termination or reduction of hours, of the covered employee's employment. One of the following:
  • Prior coverage certificate
  • Front and back of previous carrier's 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 divorce or legal separation of the covered employee from the employee's spouse. One of the following:
  • Prior coverage certificate.
  • Front and back of previous carrier's ID card
The enrollee loses a dependent or is no longer considered a dependent through divorce, legal separation or dissolution of domestic partnership as defined by state law in the state in which the divorce, legal separation or dissolution of domestic partnership occurs or if the enrollee or enrollee's dependent dies. One of the following:
  • Front and back of previous carrier's ID card
  • Max age letter from previous carrier.
The covered employee becoming entitled to benefits under Medicare. Up to sixty (60) days AFTER date of qualifying event: First of the month following date application is received. One of the following:
  • Prior coverage certificate.
  • Front and back of previous carrier's ID card
  • Eligibility document
A dependent child ceasing to be a dependent child under the generally applicable requirements of the plan. One of the following:
  • Prior coverage certificate.
  • Front and back of previous carrier's ID card
  • Max age letter from previous carrier.
Loss of minimum essential coverage for any reason other than failure to pay premiums or situations allowing for a rescission for fraud or intentional misrepresentation of material fact.
  • Letter from applicant supporting qualifying event.
  • Letter from previous carrier documenting loss of coverage.
Termination of employer contributions. Notice from employer of contributions termination.
Exhaustion of COBRA continuation coverage. COBRA paperwork reflecting exhaustion of coverage.
Loss of medically needy coverage under Medi-Cal (Medicaid). Medicaid and/or Medi-Cal documentation.
Loss of pregnancy-related coverage under Medicaid and/or Medi-Cal. Medicaid and/or Medi-Cal documentation.
Losing eligibility for coverage under a Medicaid plan under XIX of the Social Security Act or a state child health plan under XXI of the Social Security Act. Medicaid documentation.
Becoming eligible for assistance under a Medicaid plan or a state child health plan. Medicaid documentation.

Other Qualifying Events

Qualifying event Effective date determination Documentation
The enrollee or enrollee's dependent's enrollment or non-enrollment in a health plan is unintentional, inadvertent, or erroneous and is the result of the error, misrepresentation, misconduct, or inaction of an officer, employee, a non-Exchange entity providing enrollment assistance or conducting enrollment activities, or agent of the Exchange or the Department of Health and Human Services, or its instrumentalities as evaluated and determin ed by the Exchange.1 Management review and approval.
  • Front and back of previous carrier ID card.
  • Letter from Exchange or HHS documenting qualifying event.
The health plan in which the enrollee or enrollee's dependent is enrolled in substantially violated a material provision of its contract.1
  • Resolution document from the Exchange or other plan.
The enrollee demonstrates to the Exchange that he or she did not enroll in a health benefit plan during the immediately preceding enrollment period available to the individual because he or she was misinformed that he or she was covered under minimum essential coverage. Up to sixty (60) days AFTER date of qualifying event: First of the month following date application is received.
  • Letter from applicant supporting qualifying event.
  • Copy of the plan renewal letter.
The enrollee is a member of the reserve forces of the United States military returning from active duty or a member of the California National Guard returning from active duty service under Title 32 of the United States Code. Active duty discharge documentation
Release from incarceration Probation or parole release paperwork showing date of event.
The enrollee is a victim of domestic abuse or spousal abandonment, including a dependent or unmarried victim within a household, and is enrolled in minimum essential coverage and seeks to enroll in coverage separate from the perpetrator of the abuse or abandonment; or is a dependent of a victim of domestic abuse or spousal abandonment, on the same application as the victim. A signed written statement under penalty of perjury stating enrollee's name and names of the victims of domestic abuse who enrolled in coverage.
The enrollee or enrollee's dependent applies for coverage through Covered CaliforniaTM during the annual open enrollment period or due to a qualifying event, is assessed by Covered California as potentially eligible for Medi-Cal, and is determined ineligible for Medi-Cal either after open enrollment has ended or more than 60 days after the qualifying event; or applies for coverage with Medi-Cal during the annual open enrollment period and is determined ineligible after open enrollment has ended. Denial of eligibility letter from Covered California or Medi-Cal.
The enrollee adequately demonstrates to Covered California that a material error related to plan benefits, service area or premium influenced his or her decision to purchase coverage through Covered California. A signed written statement under penalty of perjury stating enrollee's name, name of the health plan, what error occurred, and the date on which the error occurred.
The enrollee was receiving services under another health benefit plan, from a contracting provider who is no longer participating in that health plan, for any of the following conditions:
(a) an acute or serious chronic condition,
(b) a terminal illness,
(c) a pregnancy,
(d) care of a newborn between birth and 36 months, or
(e) a surgery or other procedure that has been recommended and documented by the provider to occur within 180 days of the contract's termination date or within 180 days of the effective date of coverage for a newly covered member, and that provider is no longer participating in the health plan.
  • Letter from health plan that documents the provider's termination from the network.
    AND
  • Letter from provider that documents the condition of the enrollee.
If the enrollee or enrollee's dependent is Native American and enrolling in a qualified health plan or changing from one qualified health plan to another, one time per month.1
  • Prior coverage certificate.
  • A letter or document on tribal letterhead showing enrollee's name and status as a federally-recognized AI/AN; or
  • A signed written statement under penalty of perjury stating enrollee's name and the tribe in which he or she belongs to.
The enrollee or enrollee's dependent gains access to a new health plan as a result of a permanent move. Up to sixty (60) days AFTER date of qualifying event: First of the month following date application is received. Copy of acceptable proof of residency documents:
  • Current driver's license or identification card.
  • Current and valid state vehicle registration form in the applicant's name.
  • Evidence the applicant is employed.
  • Evidence the applicant has registered with a public or private employment agency.
  • Evidence that the applicant has enrolled his or her children in a school.
  • Evidence that the applicant is receiving public assistance.
  • Voter registration form of receipt, voter notification card or an abstract of voter registration.
  • Current utility bill in the applicant's name.
  • Current rent or mortgage payment receipt in the applicant's name. Rent receipts provided by a relative shall not be accepted.
  • Mortgage deed showing primary residency.
  • Lease agreement in the applicant's name.
  • Government mail in the applicant's name (SSA statement, DMV notice, etc.).
  • Cell phone bill.
  • Credit card statement.
  • Bank statement or canceled check with printed name and address.
  • U.S. Postal Service change of address confirmation letter.
  • Moving company contract or receipt showing enrollee's address.
  • If enrollee is living in the home of another person, like a family member, friend, or roommate, enrollee may send a letter/statement from that person stating that he or she lives with them and isn't just temporarily visiting. This person must prove his or her own residency by including one of the documents listed above.
  • If enrollee is homeless or in transitional housing, he or she may submit a letter or statement from another resident of the same state, stating that he or she knows where enrollee lives and can verify that he or she lives in the area and isn't just temporarily visiting. This person must prove their own residency by including one of the documents listed above.
  • Letter from a local non-profit social services provider (excluding nonprofit health care providers) or government entity (including a shelter) that can verify that enrollee lives in the area and isn't just visiting.
SEP submission time frame
All SEPs except loss of coverage
60 days after event
Loss of coverage only
  • 60 days before date of event
  • 60 days after date of event
  • 1These QEs require Health Net management review and approval.

    Health Net of California, Inc. and Health Net Life Insurance Company are subsidiaries of Health Net, Inc. Health Net is a registered service mark of Health Net, Inc. All rights reserved.

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    Important Notice

    General Purpose
    Health Net's National Medical Policies (the "Policies") are developed to assist Health Net in administering plan benefits and determining whether a particular procedure, drug, service, or supply is medically necessary. The Policies are based upon a review of the available clinical information including clinical outcome studies in the peer-reviewed published medical literature, regulatory status of the drug or device, evidence-based guidelines of governmental bodies, and evidence-based guidelines and positions of select national health professional organizations. Coverage determinations are made on a case-by-case basis and are subject to all of the terms, conditions, limitations, and exclusions of the Member's contract, including medical necessity requirements. Health Net may use the Policies to determine whether, under the facts and circumstances of a particular case, the proposed procedure, drug, service, or supply is medically necessary. The conclusion that a procedure, drug, service, or supply is medically necessary does not constitute coverage. The Member's contract defines which procedure, drug, service, or supply is covered, excluded, limited, or subject to dollar caps. The policy provides for clearly written, reasonable and current criteria that have been approved by Health Net's National Medical Advisory Council (MAC). The clinical criteria and medical policies provide guidelines for determining the medical necessity criteria for specific procedures, equipment and services. In order to be eligible, all services must be medically necessary and otherwise defined in the Member's benefits contract as described in this "Important Notice" disclaimer. In all cases, final benefit determinations are based on the applicable contract language. To the extent there are any conflicts between medical policy guidelines and applicable contract language, the contract language prevails. Medical policy is not intended to override the policy that defines the Member's benefits, nor is it intended to dictate to providers how to practice medicine.


    Policy Effective Date and Defined Terms.
    The date of posting is not the effective date of the Policy. The Policy is effective as of the date determined by Health Net. All policies are subject to applicable legal and regulatory mandates and requirements for prior notification. If there is a discrepancy between the policy effective date and legal mandates and regulatory requirements, the requirements of law and regulation shall govern. In some states, prior notice or posting on the website is required before a policy is deemed effective. For information regarding the effective dates of Policies, contact your provider representative. The Policies do not include definitions. All terms are defined by Health Net. For information regarding the definitions of terms used in the Policies, contact your provider representative.


    Policy Amendment without Notice.
    Health Net reserves the right to amend the Policies without notice to providers or Members. In some states, prior notice or website posting is required before an amendment is deemed effective.


    No Medical Advice.
    The Policies do not constitute medical advice. Health Net does not provide or recommend treatment to Members. Members should consult with their treating physician in connection with diagnosis and treatment decisions.


    No Authorization or Guarantee of Coverage.
    The Policies do not constitute authorization or guarantee of coverage of any particular procedure, drug, service, or supply. Members and providers should refer to the Member contract to determine if exclusions, limitations and dollar caps apply to a particular procedure, drug, service, or supply.


    Policy Limitation: Member's Contract Controls Coverage Determinations.
    Statutory Notice to Members: The materials provided to you are guidelines used by this plan to authorize, modify or deny care for persons with similar illnesses or conditions. Specific care and treatment may vary depending on individual need and the benefits covered under your contract. The determination of coverage for a particular procedure, drug, service, or supply is not based upon the Policies, but rather is subject to the facts of the individual clinical case, terms and conditions of the Member's contract, and requirements of applicable laws and regulations. The contract language contains specific terms and conditions, including pre-existing conditions, limitations, exclusions, benefit maximums, eligibility, and other relevant terms and conditions of coverage. In the event the Member's contract (also known as the benefit contract, coverage document, or evidence of coverage) conflicts with the Policies, the Member's contract shall govern. The Policies do not replace or amend the Member contract.


    Policy Limitation: Legal and Regulatory Mandates and Requirements
    The determinations of coverage for a particular procedure, drug, service, or supply is subject to applicable legal and regulatory mandates and requirements. If there is a discrepancy between the Policies and legal mandates and regulatory requirements, the requirements of law and regulation shall govern.


    Reconstructive Surgery
    California Health and Safety Code 1367.63 requires health care service plans to cover reconstructive surgery. "Reconstructive surgery" means surgery performed to correct or repair abnormal structures of the body caused by congenital defects, developmental abnormalities, trauma, infection, tumors, or disease to do either of the following:


    1. To improve function; or
    2. To create a normal appearance, to the extent possible.


    Reconstructive surgery does not mean "cosmetic surgery," which is surgery performed to alter or reshape normal structures of the body in order to improve appearance.


    Requests for reconstructive surgery may be denied, if the proposed procedure offers only a minimal improvement in the appearance of the enrollee, in accordance with the standard of care as practiced by physicians specializing in reconstructive surgery.


    Reconstructive Surgery after Mastectomy
    California Health and Safety Code 1367.6 requires treatment for breast cancer to cover prosthetic devices or reconstructive surgery to restore and achieve symmetry for the patient incident to a mastectomy. Coverage for prosthetic devices and reconstructive surgery shall be subject to the copayment, or deductible and coinsurance conditions, that are applicable to the mastectomy and all other terms and conditions applicable to other benefits. "Mastectomy" means the removal of all or part of the breast for medically necessary reasons, as determined by a licensed physician and surgeon.


    Policy Limitations: Medicare and Medicaid
    Policies specifically developed to assist Health Net in administering Medicare or Medicaid plan benefits and determining coverage for a particular procedure, drug, service, or supply for Medicare or Medicaid Members shall not be construed to apply to any other Health Net plans and Members. The Policies shall not be interpreted to limit the benefits afforded Medicare and Medicaid Members by law and regulation.

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