Mid-Year Benefit Changes

If a member experiences certain events outside of their Initial Enrollment or Open Enrollment Period, members may request coverage under the State Plan as a result of the event. Some events that qualify members for a Special Enrollment Period include marriage, birth, adoption, divorce, domestic partnership, and loss/gain of other coverage. In order to qualify for coverage, members must complete the on-line enrollment for mid-year changes and submit the required verification documentation with 60 days of the event (91 days for birth or adoption).

Employees who waive coverage, or do not enroll in coverage, during their Initial Enrollment Period may enroll in State Plan benefits at a later date without qualifying for a Special Enrollment Period, but will only be eligible for Core Benefits (basic life, medical, and dental). However, the employee is not able to enroll a spouse/domestic partner or dependent child(ren) on the State Plan unless the dependent qualifies for a Special Enrollment Period.

Instructions for how to complete a mid-year change online. 

REQUIREMENTS FOR ADDING DEPENDENTS MID-YEAR

"Special Enrollment Period" means a period of time allowed under this Plan, other than the eligible person’s Initial Enrollment Period or an Open Enrollment Period, during which an eligible person may request coverage under this Plan as a result of certain events that create special enrollment rights.

In addition to the initial enrollment or open enrollment allowed by this Plan, certain persons may enroll during the Special Enrollment Periods described below. Dependent Verification is required for all events.

Automatic coverage of an infant born to a Plan Participant or a Plan Participant’s covered spouse begins at birth for a thirty-one (31) day period. Automatic coverage for a thirty-one (31) day period does not apply to the newborn grandchild of a Plan Participant or a Plan Participant’s covered spouse. Permanent coverage becomes effective as stated below for birth, adoption and Placement for Adoption if the Employee completes the online life event application and verification of dependent eligibility documentation is submitted within ninety-one (91) days of the special enrollment event.

Coverage becomes effective as stated below for all other special enrollment events, including legal guardianship, if the Employee completes the online life event application and verification of dependent eligibility documentation is submitted within sixty (60) days of the special enrollment. If coverage becomes effective due to Loss of Coverage, documentation showing proof of loss will also be required to be submitted within sixty (60) days of the loss.

1. An eligible Employee or Retiree may enroll eligible Dependents who are acquired under the following specific events and become covered on the date of the event:
   1. Marriage to the Employee.
2. An eligible Employee or Retiree and all eligible Dependents who are not enrolled may enroll and become covered under the following specific events and coverage will become effective on the date of the event.
   1. Birth of the Participant's child; or
   2. Adoption of a child by the Employee, provided the child is under the age of 18; or
   3. Placement for Adoption with the Employee (must provide pre-adoption placement agreement), provided such Employee has a legal obligation for the partial or full support of such child, including providing coverage under the Plan pursuant to a written agreement and the child is under the age of 18;or
   4. Establishment of domestic partnership; or
   5. Establishment of legal guardianship or as a result of a valid court order or operation of law. If the Employee receives a Qualified Medical Child Support Order (QMCSO) the effective date of coverage will be the date of receipt of the QMCSO.
3. The following individuals may enroll and become covered when a Loss of Coverage is experienced, subject to the following:
   1. If the eligible Employee loses coverage, the eligible Employee who lost coverage and any eligible Dependents of the eligible Employee who also lost coverage may enroll and become covered as of the date of the loss.
   2. If an eligible Dependent loses coverage, the eligible Dependent who lost coverage and the eligible Employee who previously waived coverage may enroll and become covered as of the date of the loss.
   3. If an eligible Dependent of a covered Retiree loses coverage, the eligible Dependent who lost coverage may enroll and become covered as of the date of the loss.

    

   Loss of Coverage means only one of the following:

   1. COBRA Continuation Coverage under another plan that has been terminated or the maximum period of COBRA Continuation Coverage under the other plan has been exhausted; or
   2. Group or insurance health coverage that has been terminated as a result of termination of employer contributions* towards the other coverage; or
   3. Group or insurance health coverage (includes other coverage that is Medicare) that has been terminated only as a result of a loss of eligibility for coverage for any of the following reasons:
      1. Legal separation or divorce of the eligible Employee;
      2. Cessation of Dependent status;
      3. Death of the eligible Employee;
      4. Termination of employment of the eligible Dependent;
      5. Reduction in the number of hours of employment of the eligible Dependent;
      6. Termination of the eligible Dependent’s employer’s plan;
      7. Any loss of eligibility after a period that is measured by reference to any of the foregoing; or
      8. Any loss of eligibility for individual or group coverage because the eligible Employee or Dependent no longer resides, lives or works in the service area of an HMO or other such plan.
      *Employer contributions include contributions by any current or former employer that was contributing to the other non-COBRA coverage.
      A Loss of Coverage does not occur if coverage was terminated due to failure of the Employee or Dependent to pay premiums on a timely basis or coverage was terminated for cause.

    

4. Individuals may enroll and become covered as of the date of coverage loss under this Plan when coverage under Medicaid or any state children’s insurance program recognized under the Children’s Health Insurance Program Reauthorization Act of 2009 is terminated due to loss of eligibility, subject to the following:
   1. If the eligible Employee loses coverage, the eligible Employee who lost coverage and any eligible Dependents of the eligible Employee may enroll and become covered.
   2. If an eligible Dependent loses coverage, the eligible Dependent who lost coverage and the eligible Employee who previously waived coverage may enroll and become covered.
   3. If an eligible Dependent of a covered Retiree loses coverage, the eligible Dependent who lost coverage may enroll and become covered.
5. Individuals who are eligible for coverage under this Plan may enroll and become covered on the date they become entitled to a Premium Assistance Subsidy authorized under the Children’s Health Insurance Program Reauthorization Act of 2009. The date of entitlement is the date stated in the Premium Assistance Authorization entitlement notice issued by the applicable state agency (CHIP or Medicaid).

Change in Status

If a Covered Dependent under this Plan becomes an eligible Employee of the Employer, the Covered Dependent may continue their coverage as a Dependent or elect to be covered as a Participant, but may not be covered as both a Dependent and a Participant.

If an eligible Employee who is covered as a Participant of this Plan ceases to be an Employee of the State, but is eligible to be covered as a Dependent under another Participant, the former Employee may elect to continue their coverage as a Dependent of such Participant.

The online mid-year change will need to be completed within sixty (60) day of the date the Employee becomes or ceases to be an eligible Employee. Verification of dependent eligibility may be required to add former Employee as a Dependent.

REQUIREMENTS FOR REMOVING DEPENDENTS MID-YEAR

Each Covered Person, whether Participant or Dependent, is responsible for notifying the Plan Administrator, within sixty (60) days after loss of Dependent status due to death, divorce, legal separation or ceasing to be an eligible Dependent child. Failure to provide this notice may result in loss of eligibility for COBRA Continuation Coverage After Termination.

Coverage for a Dependent automatically terminates at 12:00 P.M. upon the earliest of the following dates, except as provided in any Continuation of Coverage Provision:

1. On the last day of the month in which the State Plan receives notice that the member or dependent gains eligibility with another Health Plan.
2. On the last day of the month in which the dependent ceases to be an eligible dependent as defined in the Plan;
3. On the last day of the month in which the member's coverage terminates under the Plan;
4. On the last day of the month in which the member ceases to be eligible for dependent Coverage;
5. On the last day of the month any required contribution is received.
6. The date the Plan is terminated;
7. The date the State terminates the dependent's coverage;
8. The date the Participant or dependent dies;
9. On the last day of the month in which the Plan receives the Plan’s Health Coverage Waiver Form for the dependent whose coverage is to be terminated; or
10. In the event notice of dependent ineligibility is not received within sixty (60) days, on the last day of the month of the month in which notification of the dependent’s ineligibility is received by the Plan.

Responsibility To Remove Ineligible Dependents

It is the member’s responsibility (Employee, Retiree, COBRA enrollee, or surviving spouse/domestic partner) to remove any Dependents that cease to be eligible from coverage within sixty (60) days of the date eligibility is lost. The Employee, Retiree, COBRA enrollee, or surviving spouse/domestic partner is responsible for repayment of any claim dollars paid out for an ineligible Dependent. Any excess benefit contributions paid for the ineligible dependent are refunded as applicable based upon the termination date assigned under "Dependent Termination".

If you have questions about your benefit deductions, contact HCBD at (800) 287-8266 or (406) 444-7462 or benefitsquestions@mt.gov.