SEP Eligibility - Eligible - MIBSGA Staging Site

SEP Qualifying Event*

I and/or my dependent(s) lost Minimum Essential Coverage
I gained or became a dependent due to marriage on:
I gained or became a dependent due to birth, adoption, or placement for adoption or foster care on:
An error occurred in my previous health plan enrollment, or I have adequately demonstrated that my previous health plan or issuer substantially violated a material provision of its contract with me
The Health Insurance Marketplace has determined that I or my dependents am/are newly eligible or ineligible for payments of the advanced premium tax credit, or have a change in cost-sharing eligibility, or misconduct by a non-Marketplace entity as of:
I gained access to new health plan options because of a permanent move on:
My current policy is ending on a non-calendar year date (a date other than December 31st), which is:
Other Qualifying Events

Please Specify Event Details*

Involuntary loss due to reasons other than non-payment of premium or rescission on:
Due to reaching the maximum age, legal separation, divorce, or death of the policyholder, as of:
I am no longer eligible for my prior health insurance plan due to termination of employment, reduction in number of hours of employment or loss of employer contribution toward my premiums, or I have exhausted my COBRA benefits as of:
I am no longer residing or living in my prior health insurance plan’s HMO service area as of:
I have a claim that would meet or exceed a lifetime limit on all benefits as of:
I have lost coverage because my plan no longer offers benefits to the class of similarly situated individuals as of:
I have lost coverage through my group HMO because I no longer reside or work in the service area and no other package is available as of:

Please Specify Event of Policyholder*

Please Specify New Dependent Due To Marriage*

Please Specify New Dependent*

Please Specify Event*

Termination of employment (losing job-based coverage for any reason, including resigning, laid off, or getting fired)
Reduction in number of hours of employment (resulting in loss of coverage)
Loss of employer contribution toward my premiums
Exhausted my COBRA benefits

Reason For Error*

Tax Credit Status or Entity Misconduct*

Other Qualifying Events*