HIPAA Special Enrollment Rights
10/13/2011 1:12 PM
Thank you to our guest contributor, Peter Antonie, for this post.
The Health Insurance Portability and Accountability Act ("HIPAA") provides certain special enrollment rights for group health plan participants when a participant gets married, has a new child through birth, adoption or placement for adoption, or loses coverage due to their spouse’s or dependent’s loss of coverage.
HIPAA requires the group health plan to allow the participant to enroll the new spouse or new child in the health plan or to enroll them self or family members in the health plan if due to loss of other coverage. Further, under cafeteria plan regulation, the marriage, new child or loss of other coverage is a status change and the participant is permitted to make a change in his or her current pre-tax election that is consistent with the event.
The “P” in HIPAA is Portability. The intent is that individuals can be added to a group health plan under the special enrollment rights, without regard to prior health history, when certain events occur – thus assuring that coverage is “portable” from one plan to another and individuals do not fall through the cracks and end up with large out-of-pocket medical expenses.
The special enrollment rights only apply to non-excepted HIPAA plans – basically group medical plans (e.g., health insurance). The special enrollment rights apply for no longer than 30 days after the marriage, new child or loss of other coverage. There are other special enrollment events (e.g., a child who becomes eligible for or loses eligibility for Medicaid), but marriage, new child and loss of other coverage are the events we most commonly encounter.
Examples of excepted plans that are not subject to the special enrollment rights are free-standing dental and vision plans and most health FSAs.
For the group health insurance plan, the special enrollment rights vary depending on the event (marriage, new child, loss of coverage). Any pre-tax election change would be effective with the coverage effective date. If the employer offers more than one health insurance plan option (e.g., HMO and PPO), the participant also can change plan options.
· Marriage – the participant can add the new spouse to the group health insurance plan and any new dependents as a result of the marriage so long as the request for the enrollment is made within 30 days of the marriage. Coverage is effective no later than the first of the month following 30 days from the request for enrollment.
· Birth, adoption or placement for adoption – the participant can enroll the new child, retroactive to the date of birth, adoption or placement for adoption so long as the request for enrollment is made no more than 30 days after the birth, adoption or placement of r adoption.
· Loss of other coverage – the participant can enroll them self and any other dependents that lost the other group medical coverage so long as the request for the enrollment is made within 30 days of the marriage. Coverage is effective no later than the first of the month following 30 days from the request for enrollment.
For an excepted health FSA, the three events are status changes and the permitted election change must be requested prior to or no later than 30 days after the event. The change in election is effective the date of the event or the date the Permitted Election Change Form is signed, whichever is later. If the health FSA is not a HIPAA excepted benefit, then the health FSA election change for a new child due to birth, adoption or placement for adoption is retroactive to the date of the birth, adoption of placement for adoption, if requested within 30 days of the event.