6 life events that trigger a special enrollment

Once employees elect their health benefits and open enrollment ends, their coverage is locked in unless a qualified life change occurs. The Health Insurance Portability and Accountability Act (HIPAA) grants individuals special enrollment rights outside of open enrollment if they lose eligibility for other coverage, or experience certain life events like marriage, birth or adoption. Employers with Section 125 cafeteria plans may also permit election changes for certain events outside of HIPAA special enrollment cases.

Special enrollment rights are triggered when a

• spouse loses employer coverage following a reduction of hours,
• dependent turns 26 and “ages off” a parent’s plan,
• single mother becomes eligible for premium assistance under Medicaid or a state’s children health plan,
• divorce is finalized and the enrolled spouse loses plan eligibility
• couple has a new child, and
• couple marries and the mother’s children are adopted by the new spouse.

Employers have an obligation to inform employees of their special enrollment rights under HIPAA, including coverage provided by Medicaid or the Children’s Health Insurance Program. Even though an individual may qualify for a mid-year plan change, the election change must be made within 30 days of the loss of coverage or qualified life event. For those who lose coverage under Medicaid or a state’s children health insurance program the enrollment change must be made within 60 days. If these windows are missed, coverage changes are no longer permitted until the next open enrollment or a new, qualified event occurs.

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