Late Enrollee Group Employer Plans
Qualifying – Trigger Event  QLE and get a Special Enrollment?

Special Open Enrollment – Late Enrollee
Employer Group Plans

If you or your dependent(s) (including a spouse/domestic partner), didn’t enroll in an Employer Group plan when you were first employed, you may be able to enroll yourself or your dependent(s) in this health benefit plan or change health benefit plans as a result of certain

Special Open Enrollment for entire group – Don’t have to meet contribution or Participation requirements 

Qualifying triggering events, including:

(1) you or your dependent loses minimum essential coverage;

A.   Voluntary loss doesn’t count into the Individual Market and probably not for group. Health Care.Gov *  As President Trump said Insurance is very complicated.

(2) you gain or become a dependent;

(3) you are mandated to be covered as a dependent pursuant to a valid state or federal court order;

(4) you have been released from incarceration;

(5) your health coverage issuer substantially violated a material provision of the health coverage contract;

(6) you gain access to new health benefit plans as a result of a permanent move;

I don’t see a move in the CFR  maybe it’s just a CA rule?  Just a Blue Cross rule, in their application.

Individual Rules on permanent moves.  It’s virtually the same wording, gain access as a result of a permanent move.  See also the Insurance Company Interpretations available on that page.

(7) you were receiving services from a contracting provider under another health benefit plan, for one of the conditions described in Section 1373.96(c) of the Health and Safety Code and that provider is no longer participating in the health benefit plan;     See our webpage on continuity of care

(8) you are a member of the reserve forces of the United States military or a member of the California National Guard, and returning from active duty service;

or

(9) you demonstrate to the department that you did not enroll in a health benefit plan during the immediately preceding enrollment period because you were misinformed that you were covered under minimum essential coverage.

You must request special enrollment within 60 days from the date of the triggering event to be able to enroll yourself or your dependent(s) in this health benefit plan or change health benefit plans as a result of a qualifying triggering event. Specimen Policy Page 121 *  Blue Cross Group Employee Application  * CFR 54.9810-6  Health Care Reform Regulation on Special Enrollment for Employer Plans 

 1357.500.  As used in this article, the following definitions shall apply:

(f) “Late enrollee” means an eligible employee or dependent who has declined enrollment in a health benefit plan offered by a small employer at the time of the initial enrollment period provided under the terms of the health benefit plan consistent with the periods provided pursuant to Section 1357.503 and   who subsequently requests enrollment in a health benefit plan of that small employer, except where the employee or dependent qualifies for a special enrollment period provided pursuant to Section 1357.503.

10753 (l) “Late enrollee” means an eligible employee or dependent who has declined health coverage under a health benefit plan offered by a small employer at the time of the initial enrollment period provided under the terms of the health benefit plan consistent with the periods provided pursuant to Section 10753.05 and who subsequently requests enrollment in a health benefit plan of that small employer, except where the employee or dependent qualifies for a special enrollment period provided pursuant to Section 10753.05. It also means any member of an association that is a guaranteed association as well as any other person eligible to purchase through the guaranteed association when that person has failed to purchase coverage during the initial enrollment period provided under the terms of the guaranteed association’s health benefit plan consistent with the periods provided pursuant to Section 10753.05 and who subsequently requests enrollment in the plan, except where the employee or dependent qualifies for a special enrollment period provided pursuant to Section 10753.05.

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4 comments on “Late Enrollee – Triggers – Qualifying Events

  1. Can one #change plans if they have a qualifying event like a new born or only enroll or add dependents?

    Question

    I have a PPO through my employer, and I am having a baby in September of this year.  I thought that it was either a California or Federal law that this was a qualifying event and meant that I could change health plans.  The screenshot from the CA department of Insurance that I’ve enclosed seems to say that.  However, my employer says that isn’t the case and that only applies to individual plans.

    What do you think?

    Answer

    It appears that unlike Individuals who can change plans during a qualifying event – trigger, group plans only allow dependents to be added or new enrollment, not to change plans.  This opinion  is based on:

    See the various Insurance Company Administrative Pages 

    shrm.org/

    Qualifying Life Events – insurance.ca.gov

    Individual/Family and Group health coverage sold in California only allows new membership during an annual open enrollment period. Enrollment works this way because if people were allowed to purchase insurance anytime, people could wait until they got sick and the system wouldn’t work.

    There are exceptions to the annual open enrollment period. These are called qualifying life events and if you experience one or more of them, you can buy new coverage or change your existing coverage. Below is a list of the qualifying life events:

    Individuals     *   Employer Group

    54.4980B-4

  2. I work and live mostly in CA and I’m covered under my CA employer’s group health plan. I will be telecommuting from Nevada starting next month. Does that allow me a “special enrollment” QLE as a permanent move so that I can enroll in my wife’s group insurance plan? It allows better provider network as most everything is out of network on the CA plan.

    • IMHO I’d say that you got access to the Nevada plans at the last open enrollment for your wife’s plan or when you got married or when you moved, not decided to telecommute. See # 6 above. So no, you’d have to wait for open enrollment. Individual Plans would not be available either.
      Maybe your job change to telecommuting would not allow or provide medical benefits, change in employment status. Then you’d be able to get an employer letter that you have a loss of coverage # 1. # 4 on Blue Shield interpretation

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