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Dependent Coverage - Who is Responsible?


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Hi. I have a question regarding responsibility for adding dependent coverage. Here is the scenario. It is fuzzy at best, but this is what I understand happened:

Employer hired employee that was pregnant. Employee enrolled in employer's health plan. Employee had baby. Employer continued paying Employee's health insurance premiums (even Employee's portion). Eventually, Employee notified Employer that she is not returning to work. One year later, Employee receives invoices from the hospital related to the care of her baby (as there was no dependent coverage elected). Employee blames Employer for not informing her of the need to add her baby as a dependent.

The part I don't understand is when a mother has a baby, at what point do the hospital charges relate to the mother (and get covered by employee-only coverage) versus when do certain hospital charges get attributed to the child (and get covered under dependent coverage).

What responsibilities does Employer have to inform Employee of rights related to dependent coverage? Employee never formally notified Employer of Employee's desire to add a dependent; but all parties knew that Employee was on the company health plan, and was about to have a baby.

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What responsibilities does Employer have to inform Employee of rights related to dependent coverage?

The employer has to provide the employee with an SPD for the health plan, and the SPD has to explain eligibility requirements, which would include a description of the circumstances and rules for special enrollment periods, such as, after the birth of a child.

It'd be nice if the employer reminded the employee about maybe enrolling the child, but I don't think that's required.

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Not my area of expertise but in my wife's plan it was pretty clear that you had to add dependents 30 days after birth to keep them covered. Otherwise you had to add them at next open enrollment.

Not sure why ee wouldn't have called shortly after birth for something so important as infant coverage but I I agree with GMK, other than giving SPD reminders of coverage are probably a courtesy rather than a requirement.

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Let me caution you first that there could be a variety of answers for this question and it is best to read the employer health document. But as a general rule, it is the employee's responsiblity to enroll the new dependent. In the case of a new born, the employee has 31 days to enroll. Usually, the newborn is automatically COVERED, NOT ENROLLED, by the plan and coverage will only be continued if enrolled by the employee within the 31 days.

Short of providing the employee with enrollment materials, there is no legal requirement that the employer notify or remind the employee later on.

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Let me caution you first that there could be a variety of answers for this question and it is best to read the employer health document. But as a general rule, it is the employee's responsiblity to enroll the new dependent. In the case of a new born, the employee has 31 days to enroll. Usually, the newborn is automatically COVERED, NOT ENROLLED, by the plan and coverage will only be continued if enrolled by the employee within the 31 days.

Short of providing the employee with enrollment materials, there is no legal requirement that the employer notify or remind the employee later on.

But Employer had the responsibility to provide Employee with a notice of HIPAA Special Enrollment Rights upon learning of the pregnancy, correct? I believe that Employer provided Employee with an SPD when she enrolled. But I fear that Employer did not provide the HIPAA SER when the baby was born.

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Let me caution you first that there could be a variety of answers for this question and it is best to read the employer health document. But as a general rule, it is the employee's responsiblity to enroll the new dependent. In the case of a new born, the employee has 31 days to enroll. Usually, the newborn is automatically COVERED, NOT ENROLLED, by the plan and coverage will only be continued if enrolled by the employee within the 31 days.

Short of providing the employee with enrollment materials, there is no legal requirement that the employer notify or remind the employee later on.

But Employer had the responsibility to provide Employee with a notice of HIPAA Special Enrollment Rights upon learning of the pregnancy, correct? I believe that Employer provided Employee with an SPD when she enrolled. But I fear that Employer did not provide the HIPAA SER when the baby was born.

The responsibility to provide the notice is not at the pregnancy, it is at or before the time an employee is offered the opportunity to enroll. Since the employee was already on the medical plan I am assuming that the Special Enrollment rights notice was provided with the original packet of information was given to the employee.

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