Understanding HIPAA Special Enrollment

Compliance, Employee Benefits

HIPAA Special Enrollment Events

There are many times after initial enrollment or annual enrollment that employers are asked whether or not an employee can add either themselves or a spouse or dependent(s) to the health plan. The Health Insurance Portability and Accountability Act of 1996 (HIPAA) requires that health plans provide a special enrollment upon the occurrence of certain events. Each of those events are described below.

Marriage, Birth or Adoption

Assuming that the employee, spouse and dependents would otherwise be eligible for coverage under the employer’s plan, following the marriage or birth or adoption of a child, special enrollment would allow the employee, his or her new spouse, and new dependents to all enroll under the plan. To qualify, the employee must notify the plan of the marriage, birth or adoption within 30 days of the occurrence. For birth or adoption, coverage will begin retroactively to when the event occurred.

It is important to remember that the following individuals would be eligible to enroll upon the acquisition of a new dependent through birth, marriage, adoption or placement of adoption.

  • Current employee who is eligible but not enrolled
  • Current employee who is eligible but not enrolled and new spouse
  • Current employee who is eligible but not enrolled and the newly acquireddependent
  • Spouse of current enrolled employee
  • Current employee who is eligible but not enrolled and the spouse and newly acquired dependents
  • Newly acquired dependent of a current enrolled employee

Loss of Other Coverage

Employees, spouses and dependents may also enroll in the plan if:

  • The employee, spouse and dependents are otherwise eligible to enroll
  • The employee, spouse or dependents had coverage under another group health plan coverage was previously offered AND
  • The employee, spouse or dependents lost eligibility for other coverage as a result of any one of the following:
  • The previous coverage was COBRA coverage and the maximum coverage period was exhausted
  • The previous coverage was non-COBRA and the coverage terminated due to loss of eligibility OR
  • The previous coverage was non-COBRA and the employer contributions were terminated

Loss of eligibility” means a loss of coverage under the terms of the plan. This would include divorce, dependent attainment of maximum age, death, termination of employment and reduction of hours.1

Key Takeaways

Understanding the various benefits enrollment options is important. Employers should review their plan documents and summary plan descriptions to ensure that they understand what election changes are permitted and how those impact various coverage options when employees wish to add dependents as their families grow or change.

1 Each state may have their own special enrollment rules that are more favorable than the federal HIPAA Special Enrollment requirements. For instance, in Wisconsin special enrollment is allowed in circumstances where an employee’s other coverage was simply “exhausted or terminated”. Wis. Stat. 632.746(6)

The information provided is a summary of laws and regulations relating to employee benefit plan compliance. This information should not be construed as legal advice. In all cases, employers should consult with their own legal counsel.

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