Special Enrolment Opportunities in Health Coverage.

By: Taylor


A special enrolment right gives an individual who was previously declined health coverage the right to get enrolled for coverage. Special enrolment rights are not dependant on planís open enrolment period. There are two types of special enrolment. The first enrolment right offers coverage rights to employees and dependents who decline coverage as they have other health coverage and then lose eligibility or lose employer contributions. The second type of special rights offers coverage in case of certain life events. In this case employees, spouses, and new dependents are permitted for special enrolment due to marriage, birth, adoption, or placement for adoption.

For special enrolment employee are required to request enrolment within 30 days of the loss of coverage or life event. Employees and their dependents who lose coverage under a State Childrenís Health Insurance Program (CHIP) or Medicaid or who are eligible to receive premium assistance under those programs are also entitled to special enrolment rights.

Loss of eligibility for coverage

There are many factors which could lead to loss of eligibility for coverage. They include

Divorce or legal separation
A young dependent may lose dependant status or coverage under parents plan due to age, work, or school status
Spouseís death
End of spouseís employment
Reduction of work hours by the employer
In case of plan deciding to not cover certain group of individuals such as part time workers
The beneficiary no longer lives or works in the HMOís service area
Health claim meeting or exceeding the planís lifetime limit on all benefits
All these factors could trigger loss of eligibility of the coverage. In that case an individual can be entitled to a special enrolment right.

Time taken for special enrolment

The employee or dependent are required to request special enrolment within 30 days after losing eligibility for coverage or other factors. These factors may include marriage, birth, adoption, or placement for adoption. In case of the loss of coverage under a State CHIP or Medicaid program or the determination of eligibility for premium assistance under those programs, the employee or dependent must request enrolment within 60 days of loss of coverage.

In case of request of coverage due to birth, adoption, or placement for adoption the coverage begins no later than the day of the event. In case of marriage or loss of eligibility for other coverage, the coverage begins on the first day of the first month after request being made to the plan.

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