elaws - Health Benefits Advisor
elaws - employment laws assistance for workers and small businesses - Health Benefits Advisor

Group Health Coverage through My Job or My Spouse's Job

If certain conditions are met, you may have the opportunity for special enrollment as well as other enrollment opportunities in a group health plan offered by your or your spouse's employer, employee organization (such as a union), or both, even if you were not previously enrolled in the plan and regardless of when the plan otherwise permits enrollment.

Qualifications for Special Enrollment

You may qualify for special enrollment in your job's group health plan if:

  1. You are otherwise eligible for coverage under your plan;
  2. You were covered under your parent’s plan when enrollment in your plan was previously offered and declined; and
  3. You became ineligible for coverage under your parent’s plan because you ceased to be a dependent child as defined by your parent's plan.

If you are married, you may also qualify for special enrollment in your spouse’s group health plan if:

  1. You are otherwise eligible for coverage under your spouse’s plan;
  2. You were covered under your parent’s plan when enrollment in your spouse’s plan was previously offered and declined;
  3. You became ineligible for coverage under your parent’s plan because you ceased to be a dependent child as defined by your parent’s plan; and
  4. Your spouse is already enrolled in his or her plan or is enrolling in the plan with you.

Note: If you are losing dependent child status because you got married, you may want to review the information under the Marriage section of the Health Benefits Advisor.

Time Frames for Special Enrollment

In order to special enroll in a group health plan, you must request the enrollment within 30 days after termination of coverage under your parent’s plan. If special enrollment is properly requested:

  1. The plan must make the enrollment effective no later than the first day of the first month after the plan receives the request; and
  2. The plan may not apply a pre-existing condition exclusion of more than 12 months. Also, the plan generally must shorten any pre-existing condition exclusion period by the number of days of prior coverage that each person had.

NOTE: Even if you or your family members decide not to special enroll in your plan, it is important to try to avoid incurring a significant break in coverage, especially if you or a family member has a pre-existing condition. A significant break in coverage is a period of 63 consecutive days (or longer in some states) without health coverage. Only prior health coverage that was not interrupted by a significant break in coverage is required to be applied to shorten a pre-existing condition exclusion period. In addition, you and your family members may later qualify to buy coverage with special protections in your state if you and your family members had 18 months of coverage without a significant break and meet other conditions. Contact your state insurance department for more information.

Additional Enrollment Rights

In addition to the special enrollment rights just described, you may have other rights to enroll in your (or your spouse’s) group health plan. Additional rights to enroll may exist under the terms of your (or your spouse’s) group health plan or under state law.

To find out more about enrollment rights in your (or your spouse’s) plan:

  1. Read the notice of special enrollment rules that the plan was required to give you when you were offered the opportunity to enroll in the plan. The plan may (but is not required to) use a model description of special enrollment rules;
  2. Review the SPD (summary plan description) of your plan for information about enrollment rights; and
  3. Contact your state insurance department to find out if state law gives you or other family members additional enrollment rights.

How to Choose Among Health Coverage Options

Depending on your circumstances, you may have health coverage options available besides your group health plan (or your spouse’s). Before making any decisions, you should carefully consider information on other kinds of coverage for which you may qualify.

In choosing among the options available to you, you should review the SPD for each available group health plan to determine which plan best meets your needs. You should also review and compare the information on the other coverages for which you are eligible. In making your decision, you may want to consider such things as:

  1. Any waiting period (or affiliation period) imposed under the plans;
  2. Types of benefits offered (Is dependent coverage available? Do the benefits cover your family's medical needs?);
  3. Cost of coverage (premiums, co-payment and deductibles for prescription drugs and doctor visits);
  4. Limitations on coverage (annual or lifetime dollar limits, visit limits, pre-existing condition exclusion periods, prescription drug coverage limits or limits on the availability of doctors and hospitals); and
  5. Any exclusions from coverage (treatments, procedures, conditions or prescription drugs).

Remember, it is IMPORTANT to avoid a significant break between periods of health coverage, especially for anyone who has a pre-existing condition.

To find out about other kinds of health coverage for which you may qualify, return to the Loss of Dependent Child Status Page and select another option.