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📋 '''Qualifying event''' is a specific life or employment circumstance—defined by statute or [[Definition:Insurance policy | policy]] terms—that triggers a change in an individual's eligibility for [[Definition:Insurance | insurance]] coverage. The term is most prominent in the context of [[Definition:Health insurance | health insurance]] under U.S. federal law, where the [[Definition:Consolidated Omnibus Budget Reconciliation Act (COBRA) | COBRA]] statute and the [[Definition:Affordable Care Act (ACA) | Affordable Care Act]] enumerate qualifying events that allow individuals to enroll in, extend, or change coverage outside of the standard [[Definition:Open enrollment period | open enrollment period]]. Common qualifying events include [[Definition:Termination of employment | termination of employment]], reduction in work hours, divorce, death of the covered employee, and the birth or adoption of a child.

🔄 When a qualifying event occurs under COBRA, the [[Definition:Group health insurance | group health plan]] administrator must notify the affected [[Definition:Beneficiary | beneficiaries]] within prescribed timeframes, and those individuals then have 60 days to elect continuation coverage at their own expense (typically up to 102 percent of the plan's full cost). Under the ACA marketplace rules, a qualifying event opens a [[Definition:Special enrollment period (SEP) | special enrollment period]] of usually 60 days, during which individuals can select or switch [[Definition:Health insurance | health plans]] on the exchange. Employer [[Definition:Benefits administration | benefits administration]] platforms and [[Definition:Third-party administrator (TPA) | third-party administrators]] must build these trigger-based workflows into their systems to ensure timely notifications, accurate eligibility updates, and compliant [[Definition:Premium | premium]] billing.

🛡️ Getting qualifying-event processing right carries real financial and legal consequences for [[Definition:Insurance carrier | insurers]] and plan sponsors alike. Missed notifications can expose employers to Department of Labor penalties, and incorrectly denying a qualifying event can generate [[Definition:Litigation | litigation]] and regulatory complaints. For insurers offering [[Definition:Group health insurance | group]] or [[Definition:Individual health insurance | individual]] health products, the volume and timing of qualifying events influence enrollment patterns, [[Definition:Adverse selection | adverse selection]] risk, and cash-flow projections. [[Definition:Insurtech | Insurtech]] platforms that automate qualifying-event verification—cross-referencing employment data, vital records, and plan rules in real time—are increasingly valued by carriers and employers seeking both compliance assurance and a smoother member experience.

'''Related concepts:'''
{{Div col|colwidth=20em}}
* [[Definition:Consolidated Omnibus Budget Reconciliation Act (COBRA)]]
* [[Definition:Special enrollment period (SEP)]]
* [[Definition:Group health insurance]]
* [[Definition:Affordable Care Act (ACA)]]
* [[Definition:Open enrollment period]]
* [[Definition:Third-party administrator (TPA)]]
{{Div col end}}

Definition:Qualifying event - Revision history

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