Generally speaking, elections for group health insurance are irrevocable for the plan year under section 125 plans. However, the IRS provides specific instances when an employee can make mid-year election changes. Those “election events” are:
- Change in marital status.
- Change in number of dependents.
- Change in employment.
- Change in dependent eligibility due to plan requirements (e.g., loss of student status, age limit reached).
- Change in residence (e.g., employee or dependent moves out of plan service area).
- Significant cost changes in coverage.
- Significant curtailment of coverage.
- Addition or improvement to benefit package option.
- Change in coverage of spouse or dependent under another employer plan (e.g., spouse’s company had no insurance coverage before but now offers a plan).
- Loss of certain other health coverage (e.g., plans provided by governmental or educational institutions).
- HIPAA special enrollment right events.*
- Judgments, decrees, or orders.
- Entitlement to Medicare or Medicaid.
It is important to note that if a change in status does occur, the election changes should be consistent with that event. For example, if an employee divorces, the employee may drop coverage for the spouse.
*HIPPA Special Enrollment Right Events
If you are declining enrollment for yourself or your dependents (including your spouse) because of other health insurance or group health plan coverage, you may be able to enroll yourself or your dependents in this plan if you or your dependents lose eligibility for that other coverage (or if the employer stops contributing towards your or your dependents’ other coverage). However, you must request enrollment within 30 days after your or your dependents’ other coverage ends (or after the employer stops contributing toward the other coverage).
In addition, if you have a new dependent as result of marriage, birth, adoption, or placement for adoption, you may be able to enroll yourself and your dependents. However, you must enroll within 30 days after the marriage, birth, adoption, or placement for adoption.
A special enrollment opportunity may be available in the future if you or your dependents lose other coverage. This special enrollment opportunity will not be available when other coverage ends, however, unless you provide a written statement now explaining the reason that you are declining coverage for yourself or your dependent(s). Completing the Waiver section on the Benefit Acknowledgment Form is sufficient documentation as long as you select the appropriate reason for waiving coverage. Failing to accurately complete and return this form will eliminate this special enrollment opportunity for the person(s) for whom a statement is not completed, even if other coverage is currently in effect and is later lost.
In addition, unless you indicate in the statement that you are declining coverage because other coverage is in effect, you will not have this special enrollment opportunity for the person(s) covered by the statement. (See the paragraph above, however, regarding enrollment in the event of marriage, birth, adoption or placement for adoption.)
Effective April 1, 2009 special enrollment rights also exist in the following circumstances: In the two below listed circumstances only, you or your dependents will have sixty (60) days to request special enrollment or dis-enrollment in the group health plan coverage.
- If you or your dependents experience a loss of eligibility for Medicaid or your State Children’s Health Insurance Program (SCHIP) coverage; or
- If you or your dependents become eligible for premium assistance under an optional state Medicaid or SCHIP program that would pay the employee’s portion of the health insurance premium.
To request special enrollment or obtain more information, contact your HR Coordinator to add or delete an eligible dependent.