Special Enrollment Periods - Recent Questions
Multiple clients have asked us similar questions about special enrollment periods, HIPAA, and the ACA. Here are some general cases.
We have recently been receiving requests for an individual to join their group plan due to the individual’s ACA Marketplace plan experiencing huge premium increases, plan design changes, or deductible changes. Carriers told these client employees that these are not qualifying events allowing them to join their employer’s group insurance plan. Furthermore, these employees are told they need to wait until their employer’s open enrollment period. Is this accurate? The Marketplace open enrollment runs from November 1, 2017-December 15, 2017, with all plans becoming effective on January 1, 2018, and these employees are in a time crunch, facing unaffordable individual coverage but having to wait for part or almost all of 2018 before being able to join the group plan.
In typical group coverage, we understand that employees may change plans between spouses. For example, a husband and wife on are on the husband's group plan, but the rates are going up significantly. They can opt to decline coverage from his employer during his open enrollment, and this would be a triggering event to go onto the wife's company group plan, even if it is not her open enrollment (special enrollment period).
A spouse's open enrollment is a change in status event, regardless of whether there are any plan design or premium changes.
Employees do not have a HIPAA special enrollment right or change in status event when there is a change in cost under an individual market plan. If the carrier cancels the individual market plan at renewal (even if the carrier offers a replacement) it is a HIPAA special enrollment event for the employee.
In most cases, a change in cost or plan design under an individual market plan will not allow mid-year entry to the group plan unless the individual market plan is cancelled.
A client’s employee is on an individual plan through the Marketplace. The plan is no longer being offered for 2018 (was a $1500 HSA plan being changed to $3500 non-HSA plan). This individual should be able to get a HIPAA special enrollment to LEAVE the individual market (12/31/2017) and either go onto his employer’s group plan 1/1/18 or he can go onto the spouse's Group Plan 1/1/18 under this HIPAA Special Enrollment. Both the spouse and the individual group plans open enrollment periods are mid-year. Is this permissible?
Yes, that is correct. From: Q/A-1 of this DOL FAQ:
Under HIPAA, group health plans and health insurance issuers providing group health insurance coverage are required to provide special enrollment periods to current employees and dependents during which otherwise eligible individuals who previously declined health coverage have the option to enroll under the terms of the plan (regardless of any open enrollment period). Generally, a special enrollment period must be offered for circumstances in which an employee or dependents lose eligibility for any group health plan or health insurance coverage in which the employee or their dependents were previously enrolled, and upon certain life events such as when a person becomes a dependent of an eligible employee by birth, marriage, or adoption. […] Special enrollment periods are available in several circumstances set forth in the Departments’ regulations, including when (subject to certain exceptions) an individual loses eligibility for coverage under a group health plan or other health insurance coverage (such as an employee and dependents’ loss of coverage under the spouse’s plan), when an employer terminates contributions toward health coverage (other than COBRA continuation coverage), or when coverage is no longer offered to a group of similarly situated individuals.
A group is changing from Carefirst to Kaiser and it's their open enrollment for the new plan. There is an employee that he and his spouse don't want to go to Kaiser because they have some health issues and want to remain with their current doctors. The spouse's company's group plan is Carefirst, but it is not their open enrollment period. This couple was told the one spouse’s open enrollment is not a triggering event. If in the individual market a plan is cancelled and that is a triggering event, why wouldn't it be the same if the company cancels the plan? I believed that it would be a loss of coverage event because they are losing their Carefirst plan.
It is a change in status event under the spouse’s plan. It’s permissible under Treas. Reg. 1.125-4(f)(4). Most cafeteria plans permit changing plans when one spouse has open enrollment. Employees may make changes consistent with a spouse’s open enrollment (e.g., decline to re-enroll in coverage during one employer’s open enrollment and move to the spouse’s plan mid-year).