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HIPAA Special Enrollment Period


Guest jac

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If a participant sends notice to a plan of the birth of a child and requests enrollment of the child within the special enrollment period, but then fails to send in enrollment form and the required documents to establish the child’s eligibility for coverage, e.g., a copy of the birth certificate, within the special enrollment period, is the plan still required to cover the child back to the date of birth?

Here’s an example:

June 1 – baby born

June 6 – participant notifies plan by letter that child is born and requests enrollment in the plan

June 12 – plan sends participant enrollment form and information on documents (birth certificate) that must be submitted to establish child’s eligibility. (Plan has a 30 day special enrollment period.)

September 8 – participant sends completed enrollment form and documents (birth certificate) that establish child’s eligibility

Is the letter sent by the participant in June sufficient for purposes of the HIPAA special enrollment rules even though the participant did not complete the enrollment form and send in the birth certificate until September (long past the 30 day special enrollment period)?

I've looked at the regulations, which provide that"the plan must allow an individual at least 30 days "to request enrollment."

Any thoughts would be welcome. Thanks.

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Check your plan documents for enrollment deadlines. Our associates are given 30 days to enroll once they provide notification. If they do not enroll during the 30 days, they have to wait until AE to enroll the child. Also, another point to consider...if you let this enrollment proceed, you will be setting a precedent and will have to provide others the same ability to enroll late.

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Check your plan documents for enrollment deadlines. Our associates are given 30 days to enroll once they provide notification. If they do not enroll during the 30 days, they have to wait until AE to enroll the child. Also, another point to consider...if you let this enrollment proceed, you will be setting a precedent and will have to provide others the same ability to enroll late.

Thanks, JCJD. I have checked the plan document and the SPD for enrollment deadline information. Unfortunately, both documents only say that the participant has to provide written notice to the plan administrator. They do not say that the enrollment forms and documentation must be received by the end of the special enrollment period.

I spoke with the DOL on this yesterday. The attorney pointed me to the proposed regulations issued 12-30-04, which address this situation. The proposed rules say that proviced the participant "requested enrollment" during the special enrollment period that the plan has to give people a reasonable period after the end of the special enrollment period to complete any enrollment forms and submit required documentation and that it such forms are completed and documentation sent that the coverage must be retroactive to the date of birth. Clearly these are only proposed rules, but I think they are a good guide to the way that the DOL would interpret the special enrollment rules. The final regulations do state that the plan has to give individuals at least 30 days to "request enrollment." I think in the fact pattern I described that the participant has "requested enrollment." I am aware of the administrative complexities that might arise with interpreting the regulations in this way, but I think it is the right answer to accept the documents after the end of the special enrollment period if the participant has "requested enrollment" during the special enrollment period.

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