SPECIAL ENROLLMENT (MID-YEAR CHANGE)

Subscribers on the Plan may make benefit election changes mid-year, subject to Plan restrictions, if:

  1. they have a qualifying change in status (as described below);
  2. the requested change in benefit elections is consistent with the change in status; and
  3. the request for a change in benefit elections is made within sixty-three (63) days of the event or as specifically indicated below.

An Eligible Dependent may be enrolled in the Plan during a sixty-three (63) day Special Enrollment period as provided by the Health Insurance Portability and Accountability Act (HIPAA) when one of the Special Enrollment  events (Qualifying Event or Qualifying Life Event) occurs. The sixty-three (63) day Special Enrollment period begins  on the date of the Special Enrollment event. A request for Special Enrollment must be made through the online benefits enrollment system during the sixty-three (63) day Special Enrollment period. The Subscriber must submit all required evidence of Dependent eligibility documentation within the sixty-three (63) day Special Enrollment period.

Documentation provided as evidence of a Dependent’s eligibility to support the Special Enrollment request (mid-year change) will be required as proof of eligibility and must be received within the sixty-three (63) day Special Enrollment period.

QUALIFYING EVENTS AND PERMITTED BENEFIT ELECTION CHANGES: The following are qualifying changes in status and permitted changes in benefit elections:

  1. Marriage – An Eligible Employee who marries but is not enrolled in the Plan may enroll and may enroll their new legal spouse and Eligible Dependents. A Subscriber who marries may enroll their new legal spouse and Eligible Dependents and change benefit elections, subject to Plan restrictions.

    Benefits enrollment must be completed within the sixty-three (63) day Special Enrollment period, including submission of documented evidence of Dependent eligibility. Benefit elections may be changed to reduce coverage if a Plan Participant becomes eligible for and moves to the new legal spouse’s health plan. Coverage will be effective on the first day of the month following receipt of the request for Special Enrollment.
  2. Birth – The birth of a child of an Employee who is eligible but not enrolled in the Plan allows the Employee to enroll and to enroll the newborn and other Eligible Dependents. The birth of a child of a Subscriber allows the Subscriber to enroll the newborn and other Eligible Dependents and change benefit elections, subject to Plan restrictions. Coverage of a child born to a Subscriber, covered legal spouse or covered Adult Dependent, begins on the date of birth and continues for a thirty-one (31) day period. To add the child beyond the first thirty-one (31) days, the Subscriber must affirmatively enroll the newborn child and pay the required Subscriber contribution toward premiums paid for coverage to continue beyond thirty-one (31) days. The request for Special Enrollment must be completed within the sixty-three (63) day Special Enrollment period, including submission of documented evidence of Dependent eligibility. Coverage will be effective on the newborn child’s date of birth.
  3. Adoption or Placement for Adoption – The adoption of a child by, or placement for adoption of a child with, an Employee who is eligible but not enrolled in the Plan allows the Employee to enroll and to enroll the adopted child and other Eligible Dependents. The adoption of a child by, or placement for adoption of a child with, a Subscriber allows the Subscriber to enroll the adopted child and other Eligible Dependents and change benefit elections, subject to Plan restrictions. This provision applies only to children under the age of eighteen (18). The request for Special Enrollment must be completed within the sixty-three (63) day Special Enrollment period, including submission of evidence of Dependent eligibility documentation. Coverage will be effective on the date of the qualifying adoption or placement for adoption.
  4. Divorce, legal separation, marriage annulment, dissolution of an Adult Dependent, death of a covered legal spouse or covered Adult Dependent – Benefit elections may be changed for Special Enrollment for a Dependent Child who loses eligibility under a former legal spouse’s plan, subject to Plan restrictions. Benefit elections may be changed to drop coverage on a deceased covered Dependent and on Dependents who are no longer eligible under the Plan, subject to Plan restrictions.

    An ex-spouse, legally separated spouse or Adult Dependent (and associated Dependents) must be removed from coverage within thirty (30) days of the date of the event, i.e., date of divorce decree, date of legal separation decree, or date of dissolution of Adult Dependent. The Subscriber must provide notification and event verification documentation within thirty (30) days of the date of the event to enable the Plan to remove the ex-spouse, legally separated spouse or Adult Dependent (and associated Dependents) from coverage. An ineligible Dependent should be removed from coverage within thirty (30) days of the event to avoid paying premiums that cannot be refunded. Coverage will terminate on the last day of the month in which the event occurred.
  5. A Dependent Child dies or ceases to meet the Plan’s criteria as an Eligible Dependent – Benefit elections must be changed within thirty (30) days of the event to remove an ineligible Dependent Child. A Dependent Child should be removed from coverage within thirty (30) days of the event to avoid paying premiums that cannot be refunded. Coverage will terminate on the last day of the month in which the event occurred.
  6. Loss of Eligibility for other health insurance coverage – If an Eligible Employee who is not enrolled in the Plan loses other health insurance coverage for one of the following reasons, the Eligible Employee may enroll in the Plan, along with any Eligible Dependents who have also lost eligibility for other health insurance coverage. Loss of other health insurance coverage by an Eligible Dependent of a Subscriber for one of the following reasons allows the Subscriber to enroll the Eligible Dependent and to change benefit elections, subject to Plan restrictions. Reasons for loss of health insurance coverage that trigger this provision are:
    1. The Eligible Employee or Eligible Dependent loses eligibility for other health insurance coverage (i.e., HMK, Medicaid).
    2. Employment events, such as termination of employment or reduction in work hours, resulting in a loss of eligibility for other health insurance coverage.
    3. A life event change in status resulting in loss of eligibility for other health insurance coverage (i.e., divorce or death).
    4. Loss of eligibility under other health insurance coverage due to no longer residing, living, or working in the plan’s service area.
    5. The Eligible Employee or Eligible Dependent loses COBRA insurance coverage under another plan because the COBRA continuation period is exhausted.
    6. The Eligible Employee or Eligible Dependent loses other employer insurance coverage because the plan is terminated by the employer.

      Benefits enrollment must be completed within the sixty-three (63) day Special Enrollment period, including submission of documented loss of eligibility for other coverage and evidence of Dependent eligibility. Coverage will be effective on the first day of the month following the receipt of the request for Special Enrollment.

      Loss of eligibility for other coverage when coverage was terminated due to failure of the Enrollee or Eligible Dependent to pay premiums or when coverage was terminated for cause does not constitute a Qualifying Event.

      Voluntary cancellation of other insurance coverage does not constitute a Qualifying Event.

      Certificates of Creditable Coverage do not provide proof of loss of eligibility for other health insurance coverage and are not accepted as documentation for a Qualifying Event enrollment.
  7. Eligible Dependents may enroll when coverage under Medicaid or any state children’s insurance program recognized under the Children’s Health Insurance Program Reauthorization Act of 2009 (CHIPRA/Healthy Montana Kids (HMK)) is terminated due to loss of eligibility (i.e., age or income qualifications). Benefits enrollment must be completed within the sixty-three (63) day Special Enrollment period, including submission of documented evidence of loss of eligibility for other coverage and evidence of Dependent eligibility. Coverage will be effective on the first day of the month following the receipt of the request for Special Enrollment.

    Voluntary cancellation of or failure to re-apply for Medicaid or CHIPRA insurance coverage does not constitute a Qualifying Event.
  8. Eligible Dependents may enroll when they become entitled to a Premium Assistance Subsidy authorized under the Children’s Health Insurance Program Reauthorization Act of 2009. The date of entitlement will be the date stated in the Premium Assistance Authorization entitlement notice issued by the applicable state agency (HMK or Medicaid). Benefits enrollment must be completed within the sixty-three (63) day Special Enrollment period, including submission of documented evidence of Dependent eligibility. Coverage will be effective on the first day of the month following the Plan’s receipt of the request for Special Enrollment.
  9. Court-ordered permanent legal custody or court-ordered permanent legal guardianship of a child – A court order awarding permanent legal custody or permanent legal guardianship of a child to a Subscriber or a Subscriber’s legal spouse allows the Subscriber to enroll the child, provided the child is an Eligible Dependent. Coverage will be effective on the date of the court order provided the Subscriber enrolls the child within sixty-three (63) days of the date of the court order and provides a copy of the court order.
  10. Qualified Medical Child Support Order – A Qualified Medical Child Support Order (QMCSO) requiring a Subscriber or a Subscriber’s legal spouse to provide medical insurance for the child allows the Subscriber to enroll the child within sixty-three (63) days of the Order, provided the child is an Eligible Dependent. Coverage will be effective on the first day of the month following the date of the Order provided the child is enrolled within sixty-three (63) days of the Order and a copy of the Order is provided.
  11. Gains Eligibility for other health insurance coverage – Gaining new eligibility for other health insurance coverage by a Subscriber and/or an Eligible Dependent due to one of the following causes allows the Subscriber and/or Eligible Dependent to disenroll from the Plan and/or to change benefit elections, subject to Plan restrictions:
    1. Employment events, such as new employment or newly eligible for benefits due to an increase in work hours.
    2. A change in status resulting in gaining new eligibility for other health insurance coverage (i.e., HMK, Medicaid, Medicare).

      Benefits disenrollment must be completed within the sixty-three (63) day Special Enrollment period, including submission of proof of new eligibility for other health insurance coverage from the new employer or from HMK, Medicaid, or Medicare. Coverage will terminate on the last day of the month following the receipt of the request for Special Enrollment.

      A copy of health insurance ID cards or benefits enrollment summary does not provide proof of gaining new eligibility for other health insurance coverage and is not accepted as documentation of a Qualifying Event.

      Voluntary enrollment in health insurance coverage during an employer’s annual or open enrollment period does not constitute a Qualifying Event.

RETROACTIVE PREMIUM ADJUSTMENTS: Benefit election changes for Special Enrollment are
effective on the dates indicated, subject to Plan restrictions. Premiums paid pre-tax may not be
retroactively adjusted to provide a refund more than thirty (30) days or beyond the start of the calendar
year, whichever comes first.

PREMIUM PAYMENT: Enrolling in benefits commits the Subscriber to paying the required Out-of-
Pocket monthly premiums for benefit elections through the end of the month in which the Subscriber
and their Dependents are covered. For Eligible Employees, it authorizes the MUS to deduct monthly
premium costs that exceed the employer contribution amount through payroll deduction through the
end of the month in which the Employee and their Dependents are covered.

 

Printable Qualifying Events