Changes To HIPAA Special Enrollment Provisions Under The Children's Health Insurance Program Reauthorization Act

U.S. Department of Labor
Employee Benefits Security Administration
August 2009

Under the Children’s Health Insurance Program Reauthorization Act of 2009 (CHIPRA), group health plans and group health insurance issuers must offer new special enrollment opportunities. Effective April 1, 2009, plans and issuers must permit employees and dependents who are eligible for, but not enrolled in, a group health plan to enroll in the plan upon –

• losing eligibility for coverage under a State Medicaid or CHIP program, or

• becoming eligible for State premium assistance under Medicaid or CHIP.

The employee or dependent must request coverage within 60 days of being terminated from Medicaid or CHIP coverage or within 60 days of being determined to be eligible for premium assistance.

There are also new notice and disclosure requirements associated with CHIPRA.

• Employers must notify all employees of their potential eligibility for the subsidies under Medicaid or CHIP. Model notices are to be developed by the Department of Labor and the Department of Health and Human Services (the Departments) by February 4, 2010. Employers are not required to provide these notices until the first plan year after the model notices are issued (January 1, 2011 for calendar year plans).

• In order for States to evaluate an employment-based plan to determine whether premium reimbursement is a cost effective way to provide medical or child health assistance to an individual, plans are required to provide, upon request, information about their benefits to State Medicaid or CHIP programs. The Departments, in conjunction with an advisory committee, will develop a model disclosure form by August 4, 2010. States may begin requesting this information from plans beginning with the first plan year after the model disclosure form is issued (January 1, 2011 for calendar year plans).

Individuals need to contact their State’s Medicaid or CHIP program to determine if they are eligible for Medicaid or CHIP, and to see if their State will subsidize group health plan premiums. If they are eligible for a premium subsidy, they need to contact their plan administrator or employer to take advantage of the new special enrollment opportunity and enroll in the group health plan.

Individuals needing assistance or with questions about the application of these provisions to their employment-based group health plan can call toll free 1.866.444.3272 (EBSA) to speak to a Benefits Advisor.

This fact sheet has been developed by the U.S. Department of Labor, Employee Benefits Security Administration, Washington, DC 20210. It will be made available in alternate formats upon request: Voice Telephone: 202.693.8664; Text Telephone: 202.501.3911. In addition, the information in this fact sheet constitutes a small entity compliance guide for purposes of the Small Business Regulatory Enforcement Fairness Act of 1996.