This form should be completed in order to change your healthcare information or record your Qualifying Life Event within 30 days of the event occurrence.

 

You can only cancel or enroll outside open enrollment (December) if you have a Qualifying Life Event (QLE) within 30 days.

 

Qualifying Life Event (QLE)

A change in your situation — like getting married, having a baby, or losing health coverage — that can make you eligible for a Special Enrollment Period, allowing you to enroll in health insurance outside the yearly Open Enrollment Period.

 

There are 4 basic types of qualifying life events. (The following are examples, not a full list.)

 

Loss of health coverage

• Losing existing health coverage, including job-based, individual, and student plans
• Losing eligibility for Medicare, Medicaid, or CHIP
• Turning 26 and losing coverage through a parent’s plan

 

Changes in household

• Getting married or divorced
• Having a baby or adopting a child
• Death in the family

 

Changes in residence

• Moving to a different ZIP code or county
• A student moving to or from the place they attend school
• A seasonal worker moving to or from the place they both live and work
• Moving to or from a shelter or other transitional housing

 

Other qualifying events

• Changes in your income that affect the coverage you qualify for
• Gaining membership in a federally recognized tribe or status as an Alaska Native Claims Settlement Act (ANCSA) Corporation shareholder
• Becoming a U.S. citizen
• Leaving incarceration (jail or prison)
• AmeriCorps members starting or ending their service

 

Requirements

• Supporting Documents should be attached to the form by clicking on the icon "Click to Attach Supporting document or email the document to hr@statesecurityagency.net
• Confirm Form using your company email ending in "@statesecurityagency.net" This will confirm your identity since only SSA employees have access to their company emails.

 

Enroll to SSA Healthcare Plan

To enroll to SSA's Healthcare Plan, you must complete the Healthcare Enrollment form as well by clicking HERE

 

Download Form HERE