Confirmation of Qualifying Life Event Form
Who is this for?
If you need to make changes to your individual and family plan due to a qualifying life event, you'll need to fill out this form within 60 days.
During open enrollment, you can buy a new individual and family plan or make changes to the plan you have. The changes will take place the next year.
Outside of open enrollment, you can only change your plan if you've experienced certain changes in your life circumstances. We call these events qualifying events. You won't have to wait until the next year for these changes to take effect.
After you experience a qualifying event, you'll have a special enrollment period of 60 days to change your plan or enroll in a new plan. It can happen during open enrollment, or after open enrollment has ended.
What to do
Fill out this Confirmation of Qualifying Life Event form (PDF) within 60 days of experiencing any of these life events.
- Birth, adoption, guardianship or fostering of a child
- Divorce or legal separation
- Death of the enrollee
- Loss of dependent status because you're turning 26
- Loss of Blues coverage because the enrollee is eligible for Medicare
- Loss of Blues coverage through your employer
What you’ll need to fill out the form
- The date of your life event.
- Your Blues ID card. You'll only need this if you already have a plan with us and you're losing your coverage.
- If you've already submitted an application for health care coverage with us, you'll need your application ID and the date you submitted it.
How to submit the form
- With your electronic application: If you're applying for coverage through bcbsm.com, you can scan this form and attach it to your application before you submit it.
- By email: You can also scan this form and email it to the address listed on the form.
- By fax: Fax it to the number listed on the form.
- By mail: Send it to the address listed on the form.
If you have any questions, call the number on the back of your Blues ID card. If you don't have a plan with us, you can connect with an agent or call a health plan advisor at 1-855-237-3501.