Thomas Jefferson University
STUDENT HEALTH INSURANCE PLAN

Qualifying Event Enrollment Form

A qualifying event is an event like losing minimum essential health coverage or moving. These changes can make you eligible for a special enrollment period, allowing you to enroll in the student health insurance outside the open enrollment period. 

You can use this form to enroll in the Jefferson student health insurance plan. Please contact University Health Plans at 833-207-7789 for eligibility if you have a qualifying event not listed below.

Loss of Minimum Essential Health Coverage (losing health coverage through employer, parent's plan, or Medicaid)

Changes in Household (getting divorced or death in the family)

Changes in Residence (entry into the US or moving out of existing coverage area)

All qualifying events require documentation to provide proof of your qualifying event. If you have questions about the documentation required, please contact University Health Plans at 833-207-7789 before you submit your enrollment form. 

Enrollment Deadline: The qualifying event enrollment form, payment, and required documentation must be received within 30 days from the qualifying event date.