Fillable Documentation Of Triggering Event Form

STEP 2: Triggering-event information

Under “Loss of health care coverage,” the date of the triggering event is the last full day of coverage under your prior plan.

When adding a dependent due to birth, adoption, foster care, or placement for adoption or foster care, you have 2 options for listing the date of your

triggering event. Choose the date of birth, adoption, foster care, or placement for adoption or foster care, or the first day of the following month.

Whichever option you choose will be your effective date.

List the number of your triggering event from Step 3 and the date of the event.

Triggering-event number from Step 3

Date of triggering event (mm/dd/yyyy)

STEP 3: Triggering-event information documentation

Please review the list below and see what documents you need to submit to support your triggering event. Only 1 document is required, unless

otherwise noted. For instructions on submitting your documentation, see “How to use this form” on page 1 of this form.

Check 1 box for your triggering event and 1 box for the documentation you’re submitting for it.

Triggering events and documentation required (copies only)

1. Loss of health care coverage

6. Permanent relocation

Letter stating why you lost your coverage

Proof of minimum essential coverage (MEC) in the last

60 days from prior carrier and one of the following:

2. Gaining or becoming a dependent through birth,

Utility bill

adoption, foster care, or placement for adoption or

Copy of rent agreement

foster care, marriage, or domestic partnership

Birth certificate or

7. Change in eligibility for federal financial

Letter from the medical center or birthing

assistance through Covered California

center showing proof of birth or documentation

Copy of most recent eligibility determination from

demonstrating birth at home

Covered California

Adoption papers or

8. Change in eligibility for employer health coverage

Proof of placement for adoption or foster care

Letter stating how your employer coverage changed

Evidence of proof from a court, Department of Social

and that you’re now eligible for federal financial

Services, or other agency that you have been appointed

assistance

as the foster parent

9. Determination by Covered California

Marriage license or

Notice from Covered California stating you’re eligible

Proof of domestic partnership

for a special enrollment period

3. Losing a dependent through divorce, dissolution

10. Release from incarceration

of domestic partnership, or legal separation

Release order

Divorce decree, dissolution agreement, or separation

agreement

11. Misinformation about coverage

4. Death of the subscriber or a dependent

Notice from Covered California stating you’re eligible

for a special enrollment period

Death certificate

12. Provider network changes

5. Child support order or other court order to cover

a dependent

Notice from provider stating you’re eligible for a

special enrollment period

A copy of the court order

By submitting a signed application or Account Change Form and supporting documentation along with this form, you are confirming that a triggering

event occurred. It’s important that we receive this form and your documentation because we will rely on them to determine that you’re eligible to

enroll during a special enrollment period. If we determine that the triggering event did not occur, we may take legal action, including, but not

limited to, terminating your coverage retroactively back to the effective date of coverage. You may also be financially liable for any services that

you may have received.

60433609 California January 2017

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Documentation Of Triggering Event Form - 2017 Page 3

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