American Indians & Alaska Natives

Under the Affordable Care Act (ACA), members of federally recognized tribes can enroll or change plans once per month through Your Health Idaho. For more information, visit the Tribal Members page, or contact Your Health Idaho at 855-944-3246.

For existing accounts, please visit the Report a Change page to learn more about how to report your QLE.

For new customers, please complete the form below to submit your QLE to Your Health Idaho for review.


Request for Special Enrollment


Instructions

**Please keep a copy of all forms for your records**

If you believe you have a Qualifying Life Event that might be eligible for a Special Enrollment Period, you have 60 days from the date of your event to complete the following:

  • Report your Qualifying Life Event.
  • Provide documentation to prove the event and enrollment eligibility.
  • Select and enroll in a plan.

To Report your Qualifying Life Event

1. Report your Qualifying Life Event by filling out the form below.
2. Submit the form to YHI with any contact method described in “YHI Contact Information.”



Type of Qualifying Life Event

A Qualifying Life Event could be eligible for a Special Enrollment Period. To see a brief description and required documentation visit our Special Enrollment Page.


If your event is not listed please call Your Health Idaho at 855.944.3246.

Explain Your Qualifying Life Event

Please provide detailed information about your Qualifying Life Event.

Verification documents may be requested after enrollment is approved. Failure to provide verification may impact the enrollment status or effectuation of the policy.



Documentation Upload

To see a brief description and required documentation visit our Special Enrollment Page.


Do you need assistance completing this Qualifying Life Event Report?

You may appoint an authorized representative.

You can give a trusted person permission to communicate about this report with us, see your information, and act for
you on matters related to this appeal, including getting information about your appeal and signing your appeal on your
behalf. This person is called an “authorized representative.” If you ever need to change your authorized representative,
contact YHI.


Notice of Privacy Practices

Your Health Idaho is committed to maintaining the privacy and security of personally identifiable information. Your
Health Idaho will use personally identifiable information only as permitted by Your Health Idaho's policies and as
required by law.

More information about Your Health Idaho's privacy and security practices and your rights is available on Your Health
Idaho's website at YHI Privacy Policy

If you need help understanding this form in another language, or if you are disabled and need help to use this form, please contact Your Health Idaho. There is no cost for assistance.


Read and Sign Below - Electronic Consent


A copy of this submission will be emailed to you and any designated authorized representatives.


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