Change in Status Question

[Guest wekiva]

I have an employee who waived all health coverage at open enrollment in May. The employee married and had a baby in July and her spouse lost his job and medical coverage in August. The employee submitted a QE change form in September requesting enrollment of self, spouse and baby in medical and self and spouse in dental, and checked off all three QE reasons: birth, marriage, and termination of spouse employment.

The employee was outside of the 30-day window to allow enrollment due to a change in marital status or a change in the number of dependents, and barely met the deadline for termination of spouse employment. My question is since the employee previously waived all coverage and her spouse was the only family member who lost other coverage (medical only), can we allow the employee to enroll herself, her spouse and her baby in medical, and herself and her spouse in dental?

[J Simmons]

I'm impressed that the EE both got married and had a baby in July!

Off the top of my head, I thought that the parent being able to enroll mid-year was due to the addition of a dependent child. That is, a parent could 'piggy back' off of and become enrolled when a new dependent child is allowed to be enrolled mid-year. However, I do not think that you can piggy back an EE and child onto a spouse being allowed to enroll mid-year.

[Guest wekiva]

Thanks for the response. That's what I thought, too, but we have a difference of opinions in our Benefits Department so wanted to get the feedback from some other benefits pros.

[oriecat]

Agreed. If your employee did not actually lose other coverage, then she would not have a HIPAA qualifying event for special enrollment. Her time frame for HIPAA special enrollment for the marriage and birth already passed, so loss of coverage is her only option at this time and it doesn't apply.

This is assuming that when she waived coverage she was given proper notice of her HIPAA special enrollment rights so she understood how it worked and the time frames.

[oriecat]

From the DOL

http://www.dol.gov/ebsa/faqs/faq_compliance_hipaa.html

Bold added by me.

A special enrollment opportunity occurs if an individual with other health insurance loses that coverage or if a person becomes a new dependent through marriage, birth, adoption or placement for adoption.