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!

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;

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;

(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.

Learn more⇒

Scroll down for Matrix of more specific rules of each Insurance Company

Individual

Employer Group

Section 125 Cafeteria Plans What changes are permitted – 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.

Sharp Health Plan Notice  

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Schedule a Skype, Phone or Face to Face meeting

 

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 Jan. 1

 

 

(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.

Click here
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

Click here
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

None provided
Kaiser Yes Oct. 1 – Dec. 31 Jan. 1 Employee enrollment form Click here

and 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

 

2 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:

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