Mid-Year Benefit Changes (Special Enrollment Periods)

1. An eligible Employee or Retiree may enroll eligible Dependents who are acquired under the following specific events, and coverage will become covered on the date of event:
   1. Marriage to the Employee.

   2. Establishment of domestic partnership.

2. An eligible Employee, 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. A Retiree who is already enrolled may enroll newly eligible dependent when acquired below and coverage will become effective on the date of the event.
   1. Birth of the Employee or Retiree’s child or birth of the spouse or domestic partner’s child; or
   2. Adoption of a child by the Employee or Retiree, provided the child is under the age of 18; or

   3. Placement for Adoption with the Employee or Retiree (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

3. The following individuals may enroll and become covered when 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.

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 as of the date of 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 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 loss.

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).

Loss of Coverage 

Loss of coverage means one of the following:

*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 a failure of the Employee or Dependent to pay premiums on a timely basis or coverage was terminated for cause.

Court ordered enrollment

An eligible Dependent for whom the Employee is the legal guardian, or that the Employee is required to cover as result of a valid court order or by operation of law may enroll and become covered on the date the Employee assumes the legal obligation for total or partial support of the Dependent provided the Employee completes the online enrollment application and submits the required verification of dependent eligibility documentation (copy of court order) within 60 days of the date the Employee assumes the legal obligation.

If the Employer received a Qualified Medical Child Support Order (QMCSO) the effective date of coverage will be the date of receipt of the QMCSO.

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 enrollment application and any required verification of dependent eligibility documentation must be submitted within 60 days of the date the Employee becomes or ceases to be an eligible Employee. 

removing dependents mid- year

Each Covered Person, whether Employee, Retiree, or Dependent, is responsible for notifying the Plan Administrator, within 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 Dependent ceases to be an eligible Dependent as defined in the Plan;

2. On the last day of the month in which the Employee or Retiree’s coverage terminates under the Plan;

3. On the last day of the month in which the Employee or Retiree ceases to be eligible for Dependent Coverage;

4. On the last day of the month prior to the effective date in which the Dependent becomes eligible for and has enrolled in other group health plan coverage, if the Plan is notified within 60 days of the effective date of the other group health plan coverage;

5. The last day of the month for which the Employee or Retiree fails to make any required contribution for Dependent Coverage;

6. The date the Plan is terminated;

7. The date the State terminates the Dependent's coverage;

8. The last day of the month following the date the Employee dies, or the last date of the month following the date the Retiree, or other self-pay participant, or COBRA Qualified Beneficiary dies;

9. The date the Dependent dies;

10. On the last day of the month in which the Dependent experienced an event that qualifies for a Special Enrollment Period, as long as the online enrollment application and event verification documentation is submitted within 60 days of the event; or

11. In the event notice of Dependent ineligibility is not received within 60 days, on the first day of the month following receipt of online enrollment application of the Dependent’s ineligibility. This subsection does not apply if the Dependent is still eligible for Plan coverage.

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 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 terminated Dependent are refunded as applicable based upon the termination date assigned under “Dependent Termination”.

APPEALS