When can an Late Enrollee
(Someone who didn’t enroll when first eligible)
Have a Qualifying – Trigger Event QLE
and get a Special Enrollment?
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
Special Open Enrollment – Late Enrollee – 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;
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;
(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;
(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.
Scroll down for Matrix of more specific rules of each Insurance Company
Section 125 Cafeteria Plans What changes are permitted – Special Enrollment Periods?
Code of Federal Regulations CFR §146.117 Special enrollment periods.
2020 CA Mandate!
Special open enrollment period:
Help small group employees avoid tax penalties
A new California law requires all state residents to have health coverage in 2020 or face state tax penalties. To help your clients’ employees avoid these penalties, we’re offering a special open enrollment period to small group employees who previously declined coverage under their employer’s group health plan.
The special open enrollment period for these employees runs from October 1, 2019, to December 31, 2019. And their coverage will begin on January 1, 2020 – just in time for them to avoid financial penalties.
What you need to know
- Only employees and their dependents who previously declined coverage are eligible for this special open enrollment period. Employees who are already enrolled in a plan can’t make plan changes at this time.
- All eligibility requirements for enrollment in the group health plan continue to apply.
- A Summary of Benefits and Coverage (SBC) must be provided by the group to each employee as part of the group’s annual open enrollment. A separate 60-day advance notice is not required.
For more information about the new California law, visit the Franchise Tax Board.
|Carrier||Will allow SEP for employees/dependents who declined coverage||Open enrollment time frame||Effective date||Documentation required||Carrier materials|
|Aetna||Yes||Dec. 1 – Dec. 20||
(or Jan. 15 for groups with a 15th of the month anniversary effective date)
|Employee enrollment/change form||None provided|
|Anthem Blue Cross||Yes||Nov. 18 – Jan. 31||Jan. 1||Employee application||None provided|
|Blue Shield||Yes||Dec. 2 – Jan. 31||Jan. 1||
Employee enrollment form (select “Other qualifying event” under Reason for Application and write in “SB 78”)
No qualifying event date is needed.
|Cal Choice||Yes, if Special Enrollment criteria is met (see announcement)||Dec. 1 – Jan. 20||Jan. 1||
A request for “Special Enrollment”
Employee enrollment application with “SB 78” written across the top of the form
|Covered CA||Yes||Nov. 1 – Jan. 31||Jan. 1||Employee change request form (select “Loss or Gain of Other Coverage” as reason for change)||None provided|
|Health Net||Yes||Oct. 31 – Jan. 31||Jan. 1||
Employee enrollment/change form
Proof of employment
|Kaiser||Yes||Oct. 1 – Dec. 31||Jan. 1||Employee enrollment form||Click here|
|Medi Excel||Yes||Oct. 1 – Dec. 31||Jan. 1||Employee enrollment form||Click here|
|Oscar||Yes||Oct. 1 – Jan. 31||Jan. 1||Enroll online through Oscar portal||Call (800) 801-2300|
|Sharp||Yes||Nov. 1 – Dec. 31||Jan. 1||Employee application||Click here|
|Sutter||Yes||Nov. 1 – Jan. 31||Jan. 1||Employee enrollment/change form||None provided|
|United Health Care||Yes||Nov. 1 – Jan. 31||Jan. 1||Employee enrollment/change form||None provided|
|Western Health Advantage||Yes||Oct. 1 – Jan. 31||Jan. 1||Employee enrollment/change form||None provided|
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Insurance Carrier Pages
- Blue Cross – Anthem
- Blue Shield
- California Choice – A Private Exchange
- Health Net
- Kaiser Permanente
- Self Funded Plans – Ben E Lect
- Sharp Health Plan
- SHOP – Covered CA for Small Business
- United Health Plan – Pacificare