Special Enrollment, Qualifying Events,

and Enrollment Documents

You may be eligible for Special Enrollment coverage if you experience one of the Qualifying Events listed in the table below.

To apply for coverage:

1. Apply within 60 days of your Qualifying Event.

2. Submit a completed application to Sharp Health Plan. A completed application includes:

• At least one form of documentation supporting the Qualifying Event. (Required documentation listed below.) Additional documentation
may be required.
• Completed and signed application form.
Find a copy of the Special Enrollment application on our website
sharphealthplan.com/our-plans/individual-and-family-plans/enrollment-information
• First month’s premium payment.
3. Mail, fax or email you completed application (including support documentation) to:
Sharp Health Plan for Individuals and Families
Attention: Underwriting
8520 Tech Way, Suite 200
San Diego, CA 92123
Fax (858) 499-8393 | underwriting@sharp.com

For the following Qualifying Events, coverage becomes effective on the first day of the following month after receipt of a completed
application (which includes one of the following Qualifying Event documents) and premium payment.

Effective date example:

Loss of Minimum Essential Coverage date: 3/31/2017
Application submission date: 4/11/2017
Qualifying Event documentation and payment must be received no later than 4/30/2017 for a 5/1/2017 effective date

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Loss of Minimum Essential Coverage* due to one of the reasons listed below

Qualifying Event Documentation Needed

Termination of employment Letter on business letterhead from previous employer confirming all of the following
information:

• Termination reason and termination date

• Name of previous health plan and date of coverage termination
• Employer contact name, title and contact information

Status change/Reduction of hours Letter on business letterhead from employer confirming all of the following
information:

• Date of status change/reduction of hours

• Confirmation that employee is no longer eligible for coverage due to the status
change
• Name of previous health plan and date of coverage termination
• Employer contact name, title and contact information

Exhaustion of COBRA Copy of COBRA termination letter confirming exhaustion of coverage

Termination of employer contributions Letter on business letterhead from employer stating date contributions towards
employee’s premium ended

Divorce/Legal separation Copy of Dissolution of Marriage with judge’s/commissioner’s signature and

documentation demonstrating loss of coverage

Notice of Termination of Domestic Partnership (notarized) and documentation

demonstrating loss of coverage

Copy of the agreed order of legal separation and documentation demonstrating loss
of coverage

Loss of dependent status Letter/statement from prior health plan stating coverage ended due to age

Death of a covered spouse Copy of obituary or death certificate

Incurring a claim that would meet or exceed a Letter from health plan indicating the date the individual exceeded the lifetime limits
lifetime limit on all benefits on benefits

Explanation of Benefits from health plan indicating the date the individual exceeded
the lifetime limits on the benefits

Involuntary loss of other Minimum Essential Coverage* Letter from previous health plan confirming date of coverage loss and reason for loss

Gaining access to new coverage due to one of the reasons listed below

Qualifying Event Documentation Needed

Birth, adoption or placement for adoption Birth: Hospital documentation or birth certificate showing baby’s date of birth

Coverage will begin as of the date of birth or adoption Adoption: Adoption order or Final Decree

Placement for adoption: Copy of court order or Certification of Placement from the
adoption agency

Marriage or Registered Domestic Partners Copy of marriage certificate with seal or Registered Domestic Partnership certificate
(Self / Spouse / Self + Spouse)
Documentation showing marriage certificate was filed in court

Legal guardianship or medical support order Copy of court documentation of legal guardianship

Copy of Qualified Medical Support Order

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 Loss of Minimum Essential Coverage does not include termination or loss due to voluntary termination of
*

coverage, failure to pay premiums, or fraud or misrepresentation of a material fact.

Examples of Minimum Essential Coverage:

• Employer-sponsored coverage, including self-insured plans, COBRA coverage and retiree coverage
• Coverage purchased in the individual market, including a qualified health plan offered by the Health Insurance Exchange
• Government sponsored coverage (Medicare, Medi-Cal, CHIP, etc.)
• Military coverage (TRICARE)

For the following Qualifying Events:

If a completed application (which includes one of the following Qualifying Event documents) and premium payment

• Is received or postmarked (whichever is earlier) between the 1st and 15th of the month, then coverage is effective the first day of
the following month.
• Is received or postmarked (whichever is earlier) between the 16th and last day of the month, the coverage is effective the first day of
the second month.

Qualifying Event Documentation Needed

Permanent move to the service area Verification of recent address change such as utility billing statement, rental
agreement or mortgage statement (1) from the previous residence, and (2) from
the current residence

For school-aged children: school enrollment record (1) from the previous
residence, and (2) from the current residence

Released from incarceration Documentation from the releasing facility or the applicable State Department
of Justice indicating the date of release and confirming the applicant was
incarcerated during the open enrollment period

Member of the reserve force of the United States Documentation from the applicable government agency indicating the date of
military returning from active duty or a member of the return and confirming the applicant was on active duty during the previous open
California National Guard returning from active duty enrollment period
service

Previous health coverage issuer substantially violated a Written statement from applicant explaining the circumstances and the provision
material provision of the heath coverage contract of the plan contract the applicant asserts the previous health plan violated. The
written explanation must be accompanied by a copy of the Evidence of Coverage
and/or plan contract from the previous health plan

Failure to enroll in a health benefit plan during the
immediately preceding enrollment period because
applicant was misinformed that he or she was covered
under minimum essential coverage
Letter from the Department of Manage Health Care (DMHC) confirming applicant
has demonstrated the required criteria
Notice from other health plan

Previously receiving services from a contracting Documentation from prior health plan indicating the date the contracting provider
provider under another health benefit plan for one of terminated his/her contract with the plan and medical records confirming
the following services and that provider is no longer applicant was receiving treatment from the provider for one of the listed services
participating in the health benefit plan: prior to the provider’s termination. Approval is contingent upon clinical review.

• An acute condition
• Serious chronic condition
• Pregnancy
• Terminal illness
• A pending surgery or procedure that was previously
scheduled to occur within 180 days of the date your
provider was terminated from the network of your
previous health plan
• A child age 0-36 months

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