Inside Track: Know the Rules: Special Enrollment Periods for Health Insurance Plans:

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  • December

    Know the Rules: Special Enrollment Periods for Health Insurance Plans

    This is the fifth in a series of articles from the State Bar Insurance and Member Benefits Committee designed to help State Bar members better understand and evaluate their health insurance options in light of the changes coming under the federal Patient Protection and Affordable Care Act (ACA). This article is intended to be informational and is not an advertisement for insurance or giving tax or legal advice.
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    Dec. 17, 2014 – The open enrollment period for individuals and small employer groups to purchase health insurance coverage through the various online insurance Exchanges, commonly called Marketplaces, began Nov. 15, 2014, and ends on Feb. 15, 2015.

    Many employer-sponsored group health plans that are based on the calendar year are also now offering open enrollment to their plans for their eligible employees and their eligible dependents.

    An open enrollment period generally allows an eligible person to enroll in the plan during that period. Members should carefully consider coverage options during open enrollment periods because the ability to make changes other than during the plan’s applicable open enrollment period may be limited.

    If a member wishes to enroll in or change health insurance plans outside the general enrollment period, there are limited circumstances that allow it.

    Special Enrollment Periods for Exchanges

    ACA regulations found at 45 CFR §155.420 list the circumstances that will allow an individual to enroll in a qualified health plan, or change from one qualified health plan to another, under the Exchange other than during an open enrollment period. The circumstances allowing a person to enroll in an Exchange plan during a special enrollment period are:

    • A qualified individual or dependent loses minimum essential coverage;

    • A qualified individual gains a dependent or becomes a dependent through marriage, birth, adoption or placement for adoption;

    • An individual, who was not previously a citizen, national, or lawfully present individual gains such status;

    • A qualified individual’s enrollment or non-enrollment in a qualified health plan is unintentional, inadvertent, or erroneous and is the result of an error or mistake by the Exchange or the U.S. Department of Health and Human Services (HHS);

    • An enrollee demonstrates to the Exchange that the qualified health plan in which he or she is enrolled violated a material provision of its contract with the enrollee;

    • An individual becomes newly eligible or newly ineligible for advance payments of the premium tax credit or has a change in eligibility for cost-sharing reductions, regardless whether the person is already enrolled in a qualified health plan. The Exchange must permit individuals whose existing coverage through an eligible employer-sponsored plan will no longer be affordable or provide minimum value for the employer’s upcoming plan year to access this special enrollment period prior to the end of the coverage period through the employer-sponsored plan.

    • An individual gains access to new qualified health plans as a result of a permanent move;

    • An eligible Native American may enroll in a qualified health plan or change coverage once per month; or

    • A qualified individual demonstrates to the Exchange that the individual meets other exceptional circumstances as defined by the Exchange.

    There are special rules that apply to individuals losing coverage under Medically Needy Medicaid and individuals who are eligible for and/or electing health insurance under the Consolidated Omnibus Budget Reconciliation Act (COBRA). For exceptional or complex situations, speak with a health insurance advisor.

    The special enrollment period generally is 60 days from the special enrollment event. Any changes to coverage based on the special enrollment event must be made during that 60-day special enrollment period.

    These federal regulations also generally apply to ACA-covered individual health insurance policies that are offered outside the Exchange. Members can get more information about the regulations that apply to a specific plan from the health insurance company or a trusted health insurance advisor.

    Special Enrollment Periods for Employer-Sponsored Group Health Plans

    If contemplating a coverage election change that involves an employer-sponsored group health plan, consider contacting the plan’s administrator to determine the plan’s requirements for making a coverage election change.

    Plans are granted some latitude in the design of the plan regarding whether and under what circumstances to permit an open enrollment period or special enrollment period. If making elections for coverage under a cafeteria plan, those elections are generally irrevocable, unless the plan permits changes for certain election change events. These may include:

    • Change in status events including: change in legal marital status; change in the number of dependents; change in employment status; change in dependent eligibility status; change in residence; or commencement or termination of adoption proceedings;

    • Cost changes;

    • Coverage changes including: significant coverage curtailment with or without loss of coverage; addition or significant improvement of a benefit package option; change in coverage under another employer-sponsored group health plan; or Medicaid/Medical Assistance or State Children's Health Insurance Program (SCHIP) coverage changes;

    • Judgments, decrees or orders

    • Special Enrollments under the Federal Health Insurance Portability and Accountability Act (HIPAA);

    • Leaves permitted under the Federal Family and Medical Leave Act (FMLA) or the Federal Uniformed Services Employment and Reemployment Rights Act (USERRA).

    In addition, recent guidance in IRS notice 2014-55 has added two more permitted election change events for employer-sponsored group health plans.

    • Dropping coverage to elect and purchase coverage under an Exchange during the Exchange’s open enrollment period;

    • Changing coverage due to a reduction in hours worked where the reduction does not result in a loss of coverage.

    These election change events are permitted, but not required. To implement these election change events, the events must be included in the plan documents for that employer-sponsored group health plan. Members should refer to the specific requirements set forth in the plan’s documents which govern the election change events that apply to persons covered under that plan.

    All State Bar members are encouraged to utilize one of the resources below, or to connect with their own trusted tax, employee benefits, and insurance advisors to help you make the best coverage decisions for the member’s unique situation.

    Professional Insurance Programs

    Professional Insurance Programs (PIP) will provide personal assistance in evaluating health insurance coverage options and has an online health insurance shopping portal for State Bar members to help them evaluate other coverage options. PIP can be contacted at (414) 277-0154 or (800) 637-4676 or via their website.

    Bultman Financial Services

    Bultman Financial Services (BFS) will offer personal assistance in evaluating health insurance coverage options and State Bar members have access to the GOHealth online health insurance shopping portal to help them evaluate other coverage options. This shopping portal will provide access to coverage options for health insurers selling insurance in Wisconsin and those sellingacross the nation. BFS can be contacted at (262)782-9949 or (800) 344-7040 or via their website.

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