Health Insurance eligibility - special enrollment

[Guest PattyB]

An employee (A) currently enrolled in our fully insured health plan asks for a special enrolment of four children (X-Z) that are the children of her spouse.

The employee's children are already enrolled (employee with children rate). The "new" children are her spouse's (B) children (married approximately 3 months). The spouse is a part-time student with no insurance (to add him would increase their premium so they did not do it).

Now - the spouse's ex-wife © has asked the court for an order making the employee's spouse (B) responsible for insurance and medical expenses. The ex © says she can't afford the premium cost and is dropping coverage for the X-Z children.

This announcement came when it was too late to add the children during open enrollment.

Is this a special event for our plan? :confused:

[KIP KRAUS]

If these children do not live with your employee I'd say they are not eligible to enroll in your plan. Check the eligibility provisions of your fully insured contract.

[Sandra Pearce]

I agree with the previous post. You must first check eligibility in your plan. A dependent child, in our plan, must reside with the employee. Any court order issued would obligate the spouse, not the employee or the employee's employer sponsored health plan, to provide coverage.

[Guest PattyB]

Thank you for your responses, they directed me to where I would find the information I needed. Our plan definition of dependent includes step-chilren if there is a support obligation on the member or spouse. Is this unusual?

[KIP KRAUS]

Does your plan say that the stepchildren must be residing with the employee? I find it odd that the plan would not have residency requirements for stepchildren. Most fully insured contracts I’ve seen have a legal adoption or a residency requirement.

I have also never seen a court order that made the spouse of a person with children from a previous marriage responsible for such children unless they were residing with the new spouse, or legally adopted by the new spouse. That of course doesn’t mean that a court wouldn’t take such action. However, if the employee cannot provide proof of the court order I wouldn’t allow the coverage.

Check it out thoroughly.

[jsb]

Let's assume that the children are eligible dependents of your employee (they would be under my plan without regard to residence). Let's also assume that there is something that will constitute a "support order" (could be a formal medical supponr order, could be a statement from from the divorce decree, etc.). Make sure that the health carrier that will be adding the kids agrees with these determinations!

The issue then turns on 1) whether or not your plan would permit a mid-year election change under these or similar circumstances, and 2) whether they have had a "qualifying loss of coverage" under another group health plan that would permit you to make a change under your plan. If the children are losing coverage due to an annual enrollment change by the ex, this should be a valid reason to allow the change, IF your plan permits this type of change. On the other hand, if the ex is simply dropping the kids mid-year for no reason other than it is too expensive (which is not a 125 reason), this might not be a valid reason if your plan is a 125 plan. By your facts it doesn't seem that there would be a change in premium, which may permit you to allow the add without an election change.

Sometimes the easy route is to have your employee encourage the ex to get the court order. Then help out by making sure that your employee can supply the ex with suggested wording for the court order that you will need as plan administrator to permit the change! However it turns out, you have landed sqarely in your employee's corner regarding resolution of this problem.

Good luck!

[Guest PattyB]

I researched our plan - Step children are not required to live with the employee. The employee or spouse is responsible to support or providing medical insurance by court order. So the step children are eligible dependents.

So the question I have sent to the insurance company is "Is this change in the divorce degree for the non-employee a qualifing event." So we'll see.

Had this all occured 2-3 weeks earlier, the step-kids could have been enrolled during open enrollment.

[KIP KRAUS]

I find it very hard to understand why an insurer would want to cover stepchildren who don’t reside with your employee. Even if a court order exists that requires your employee to be partially responsible for her husband’s children that do not reside with her an insurer should and in most cases disallow coverage. I would get on the phone and discus this thoroughly with the insurer and provide them with all of the details. Even though your contract may not specifically mention that the stepchildren must reside with the insured the insurer may administer it that way. Unless you, as the contract holder have leeway to define who is covered as a dependent I find it hard to believe that an insurer would have this as a standard contract provision unless of course it is mandated in the state where the contract is issued.

Court orders cannot require an employer or an insurer to provide benefits to a person that normally wouldn’t be eligible for coverage under the plan.