45 C.F.R. Spouse or dependent becomes eligible for coverage (both current employee and spouse/dependent become eligible for special enrollment) Marriage (new dependents resulting from marriage included) Birth, adoption, placement for adoption RCW 48.43.517 When the Health Care Authority requests special enrollment for a child participating in a Special 45 C.F.R. Enrollment medical assistance program under chapter 74.09 RCW within 60 days of making a §146.117(a)(4)(i) Periods determination that it is cost-effective to enroll the child in that plan. (Cont’d) RCW Does the special enrollment period last at least 31 days after the qualifying event? 48.43.005(34) 45 C.F.R. Does coverage begin no later than the first day of the first calendar month beginning after the date §146.117(a)(4)(ii) the plan receives the request for special enrollment? 45 C.F.R. Exceptions: When special enrollment qualifying is: §146.117 Marriage: coverage must begin no later than the first day of the first calendar month (b)(3)(iii)(A) beginning after the date the issuer receives the request for special enrollment. Birth, adoption, placement for adoption, or new dependent as a result of marriage: 45 C.F.R. §146.117 Coverage begins on the date of dependent’s birth, adoption, placement for adoption, or (b)(3)(iii)(B) marriage if new dependent resulting from marriage Even if the special enrollment happens to coincide with a late enrollment opportunity does the plan Group Enrollment treat special enrollee as special enrollee, rather than late enrollee? 45 C.F.R. Requirements §146.117(d)(1) Are special enrollees offered all benefit packages available to similarly situated enrollees who (Cont’d) enroll when eligible? 45 C.F.R. §146.117(d)(2) Plan cannot have different terms for special enrollees: no higher rate, longer pre-existing condition exclusion, different cost sharing. and . Resources:
Group Enrollment Requirements (Cont’d) Special Enrollment Periods (Cont’d) 45 C.F.R. RCW 48.43.517 45 C.F.R. §146.117(a)(4)(i) RCW 48.43.005(34) 45 C.F.R. §146.117(a)(4)(ii) 45 C.F.R. §146.117 (b)(3)(iii)(A) 45 C.F.R. §146.117 (b)(3)(iii)(B) 45 C.F.R. §146.117(d)(1) 45 C.F.R. §146.117(d)(2) Spouse or dependent becomes eligible for coverage (both current employee and spouse/dependent become eligible for special enrollment) Marriage (new dependents resulting from marriage included) Birth, adoption, placement for adoption When the Health Care Authority requests special enrollment for a child participating in a medical assistance program under chapter 74.09 RCW within 60 days of making a determination that it is cost-effective to enroll the child in that plan. Does the special enrollment period last at least 31 days after the qualifying event? Does coverage begin no later than the first day of the first calendar month beginning after the date the plan receives the request for special enrollment? Exceptions: When special enrollment qualifying is: Marriage: coverage must begin no later than the first day of the first calendar month beginning after the date the issuer receives the request for special enrollment. Birth, adoption, placement for adoption, or new dependent as a result of marriage: Coverage begins on the date of dependent’s birth, adoption, placement for adoption, or marriage if new dependent resulting from marriage Even if the special enrollment happens to coincide with a late enrollment opportunity does the plan treat special enrollee as special enrollee, rather than late enrollee? Are special enrollees offered all benefit packages available to similarly situated enrollees who enroll when eligible? Plan cannot have different terms for special enrollees: no higher rate, longer pre-existing condition exclusion, different cost sharing. Resources: and .
checklist-forms-hmo-large-group.docx