HIPAA Special Enrollment Rights

HIPAA Special Enrollment Events are a subset of the Section 125 Election Change Events that provide special enrollment rights. But, unlike Section 125, HIPAA’s events are only about enrolling in your group health plan, not dis-enrolling. HIPAA requires group health plans to provide special enrollment opportunities outside the plan’s regular enrollment periods in certain situations, such as:

Loss of eligibility for group health coverage or individual health insurance coverage;
Loss of Medicaid/CHIP eligibility or becoming eligible for state premium assistance subsidy under Medicaid/CHIP; and
Acquisition of a new spouse or dependent by marriage, birth, adoption, or placement for adoption.

Special Enrollment Rights under HIPAA allow individuals to enroll in a group health plan outside of the regular enrollment period due to certain life events or the loss of other health coverage. These rights allow individuals and their eligible dependents to join a health plan when they experience certain events. Special enrollment must be requested within a specific time frame, typically within 30 days after the qualifying event occurs (or 60 days in the event of a Medicaid/CHIP event). The goal is to ensure that individuals have access to health insurance when significant life changes impact their coverage needs.

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 in more detail below.

Marriage, Birth or Adoption	Loss of Other Coverage*	Loss of or becoming eligible for Medicaid/CHIP subsidy
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 or 31 days of the occurrence (check plan document language for exact time frame). For birth or adoption, coverage will begin retroactively to when the event occurred.	Employees, spouses and dependents may also enroll in the plan if:	The employee or dependent must request coverage within 60 days of being terminated from Medicaid or CHIP coverage or within 60 days of being determined to be eligible for premium assistance.
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 acquired dependent 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 *Any dependent child existing prior to this event does not have a special enrollment right under HIPAA. However, just because this child does not have a special enrollment right does not mean the plan could not permit the child to be enrolled as well. Be sure to check the plan document for exceptions.	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. Please refer to the plan document as most plans require that the employees would have had to waive coverage initially in order to be eligible for a HIPAA loss of coverage event. *Loss of coverage does not include voluntary loss of coverage. This would include voluntarily terminating COBRA before the maximum period was reached, non-payment of premium and voluntarily terminating coverage (i.e., dropping off a parent’s plan before ageing out). Leaving a job, no matter the situation, counts as an involuntary loss of health insurance.	An individual can have a special enrollment right if he or she loses eligibility for Medicaid or CHIP, or gains assistance (to pay for premiums) under Medicaid or CHIP. These special enrollment rights are limited to employees and dependents. HIPAA regulations are unclear if the spouse or dependent who is not experiencing the loss in coverage is eligible for enrollment. Self-funded health plans tend to limit enrollment to employees and non-spouse dependents. However, employers may permit spouses to be enrolled in certain circumstances.

Marriage, Birth or Adoption

Loss of Other Coverage*

Loss of or becoming eligible for Medicaid/CHIP subsidy

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 or 31 days of the occurrence (check plan document language for exact time frame). For birth or adoption, coverage will begin retroactively to when the event occurred.

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

The employee or dependent must request coverage within 60 days of being terminated from Medicaid or CHIP coverage or within 60 days of being determined to be eligible for premium assistance.

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 acquired dependent
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

*Any dependent child existing prior to this event does not have a special enrollment right under HIPAA. However, just because this child does not have a special enrollment right does not mean the plan could not permit the child to be enrolled as well. Be sure to check the plan document for exceptions.

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. Please refer to the plan document as most plans require that the employees would have had to waive coverage initially in order to be eligible for a HIPAA loss of coverage event.

*Loss of coverage does not include voluntary loss of coverage. This would include voluntarily terminating COBRA before the maximum period was reached, non-payment of premium and voluntarily terminating coverage (i.e., dropping off a parent’s plan before ageing out). Leaving a job, no matter the situation, counts as an involuntary loss of health insurance.

An individual can have a special enrollment right if he or she loses eligibility for Medicaid or CHIP, or gains assistance (to pay for premiums) under Medicaid or CHIP. These special enrollment rights are limited to employees and dependents.

HIPAA regulations are unclear if the spouse or dependent who is not experiencing the loss in coverage is eligible for enrollment. Self-funded health plans tend to limit enrollment to employees and non-spouse dependents. However, employers may permit spouses to be enrolled in certain circumstances.

In all HIPAA Special Enrollment Event situations, it is important to remember that the impacted employee must first be in a benefit eligible class. HIPAA never applies if the employee in question is not benefit eligible.

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 coverage or dependents. Also, please feel free to reach out to your Diversified Group eligibility team with any questions concerning HIPAA Special Enrollment Events and their application.