When can an Late Enrollee
(Someone who didn’t enroll when first eligible)

Have a Qualifying – Trigger Event  QLE
and get a Special Enrollment?

 

NEW CA Mandate for Individuals to have Health Insurance!

Special Open Enrollment – Late Enrollee

If you or your dependent(s) (including a spouse/domestic partner), didn’t enroll in an Employer Group plan when you were first employed, you may be able to enroll yourself or your dependent(s) in this health benefit plan or change health benefit plans as a result of certain

Qualifying triggering events, including:

(1) you or your dependent loses minimum essential coverage;

A.   Voluntary loss doesn’t count into the Individual Market and probably not for group. Health Care.Gov *  As President Trump said Insurance is very complicated.

(2) you gain or become a dependent;

(3) you are mandated to be covered as a dependent pursuant to a valid state or federal court order;

(4) you have been released from incarceration;

(5) your health coverage issuer substantially violated a material provision of the health coverage contract;

(6) you gain access to new health benefit plans as a result of a permanent move;

I don’t see a move in the CFR  maybe it’s just a CA rule?  Just a Blue Cross rule, in their application.

Individual Rules on permanent moves.  It’s virtually the same wording, gain access as a result of a permanent move.  See also the Insurance Company Interpretations available on that page.

(7) you were receiving services from a contracting provider under another health benefit plan, for one of the conditions described in Section 1373.96(c) of the Health and Safety Code and that provider is no longer participating in the health benefit plan;     See our webpage on continuity of care

(8) you are a member of the reserve forces of the United States military or a member of the California National Guard, and returning from active duty service;

or

(9) you demonstrate to the department that you did not enroll in a health benefit plan during the immediately preceding enrollment period because you were misinformed that you were covered under minimum essential coverage.

You must request special enrollment within 60 days from the date of the triggering event to be able to enroll yourself or your dependent(s) in this health benefit plan or change health benefit plans as a result of a qualifying triggering event. Specimen Policy Page 121 *  Blue Cross Group Employee Application  * CFR 54.9810-6  Health Care Reform Regulation on Special Enrollment for Employer Plans 

 1357.500.  As used in this article, the following definitions shall apply:

(f) “Late enrollee” means an eligible employee or dependent who has declined enrollment in a health benefit plan offered by a small employer at the time of the initial enrollment period provided under the terms of the health benefit plan consistent with the periods provided pursuant to Section 1357.503 and   who subsequently requests enrollment in a health benefit plan of that small employer, except where the employee or dependent qualifies for a special enrollment period provided pursuant to Section 1357.503.

10753 (l) “Late enrollee” means an eligible employee or dependent who has declined health coverage under a health benefit plan offered by a small employer at the time of the initial enrollment period provided under the terms of the health benefit plan consistent with the periods provided pursuant to Section 10753.05 and who subsequently requests enrollment in a health benefit plan of that small employer, except where the employee or dependent qualifies for a special enrollment period provided pursuant to Section 10753.05. It also means any member of an association that is a guaranteed association as well as any other person eligible to purchase through the guaranteed association when that person has failed to purchase coverage during the initial enrollment period provided under the terms of the guaranteed association’s health benefit plan consistent with the periods provided pursuant to Section 10753.05 and who subsequently requests enrollment in the plan, except where the employee or dependent qualifies for a special enrollment period provided pursuant to Section 10753.05.

Learn more⇒

Individual

Employer Group

Check the Administrative Page for the relevant Insurance Company

Section 125 Cafeteria Plans What changes are permitted – Special Enrollment Periods?

Code of Federal Regulations CFR §146.117   Special enrollment periods.
See also ECFR.gov

 

 

Is your Family Protected with Life Insurance? Click here for Instant Quote

Is your Family Protected with Life Insurance? Click here for Instant Quote

 

Federal Part 146 - Requirements For The Group Health Insurance Market

PART 146 - REQUIREMENTS FOR THE GROUP HEALTH INSURANCE MARKET Authority:42 U.S.C. 300gg-1 through 300gg-5, 300gg-11 through 300gg-23, 300gg-91, and 300gg-92. Source:62 FR 16958, Apr. 8, 1997, unless otherwise noted.

  • Authority: 42 U.S.C. 300gg-1 through 300gg-5, 300gg-11 through 300gg-23, 300gg-91, and 300gg-92.
  • Source: 62 FR 16958, Apr. 8, 1997, unless otherwise noted.
45:2.0.1.1.4.1 SUBPART A Subpart A - General Provisions  
45:2.0.1.1.4.1.1.1 SECTION 146.101    146.101 Basis and scope.  
45:2.0.1.1.4.2 SUBPART B Subpart B - Requirements Relating to Access and Renewability of Coverage, and Limitations on Preexisting Condition Exclusion Periods  
45:2.0.1.1.4.2.1.1 SECTION 146.111    146.111 Preexisting condition exclusions.  
45:2.0.1.1.4.2.1.2 SECTION 146.113    146.113 Rules relating to creditable coverage.  
45:2.0.1.1.4.2.1.3 SECTION 146.115    146.115 Certification and disclosure of previous coverage.  
45:2.0.1.1.4.2.1.4 SECTION 146.117    146.117 Special enrollment periods.  
45:2.0.1.1.4.2.1.5 SECTION 146.119    146.119 HMO affiliation period as an alternative to a preexisting condition exclusion.  
45:2.0.1.1.4.2.1.6 SECTION 146.120    146.120 Interaction with the Family and Medical Leave Act. [Reserved]  
45:2.0.1.1.4.2.1.7 SECTION 146.121    146.121 Prohibiting discrimination against participants and beneficiaries based on a health factor.  
45:2.0.1.1.4.2.1.8 SECTION 146.122    146.122 Additional requirements prohibiting discrimination based on genetic information.  
45:2.0.1.1.4.2.1.9 SECTION 146.123    146.123 Special rule allowing integration of Health Reimbursement Arrangements (HRAs) and other account-based group health plans with individual health insurance coverage and Medicare and prohibiting discrimination in HRAs and other account-based group hea  
45:2.0.1.1.4.2.1.10 SECTION 146.125    146.125 Applicability dates.  
45:2.0.1.1.4.3 SUBPART C Subpart C - Requirements Related to Benefits  
45:2.0.1.1.4.3.1.1 SECTION 146.130    146.130 Standards relating to benefits for mothers and newborns.  
45:2.0.1.1.4.3.1.2 SECTION 146.136    146.136 Parity in mental health and substance use disorder benefits.  
45:2.0.1.1.4.4 SUBPART D Subpart D - Preemption and Special Rules  
45:2.0.1.1.4.4.1.1 SECTION 146.143    146.143 Preemption; State flexibility; construction.  
45:2.0.1.1.4.4.1.2 SECTION 146.145    146.145 Special rules relating to group health plans.  
45:2.0.1.1.4.5 SUBPART E Subpart E - Provisions Applicable to Only Health Insurance Issuers  
45:2.0.1.1.4.5.1.1 SECTION 146.150    146.150 Guaranteed availability of coverage for employers in the small group market.  
45:2.0.1.1.4.5.1.2 SECTION 146.152    146.152 Guaranteed renewability of coverage for employers in the group market.  
45:2.0.1.1.4.5.1.3 SECTION 146.160    146.160 Disclosure of information.  
45:2.0.1.1.4.6 SUBPART F Subpart F - Exclusion of Plans and Enforcement  
45:2.0.1.1.4.6.1.1 SECTION 146.180    146.180 Treatment of non-Federal governmental plans.

3 comments on “Late Enrollee – Triggers – Qualifying Events

  1. I work and live mostly in CA and I’m covered under my CA employer’s group health plan. I will be telecommuting from Nevada starting next month. Does that allow me a “special enrollment” QLE as a permanent move so that I can enroll in my wife’s group insurance plan? It allows better provider network as most everything is out of network on the CA plan.

    • IMHO I’d say that you got access to the Nevada plans at the last open enrollment for your wife’s plan or when you got married or when you moved, not decided to telecommute. See # 6 above. So no, you’d have to wait for open enrollment. Individual Plans would not be available either.

      Maybe your job change to telecommuting would not allow or provide medical benefits, change in employment status. Then you’d be able to get an employer letter that you have a loss of coverage # 1. # 4 on Blue Shield interpretation:

Leave a Reply

Your email address will not be published.