Clarification on Health Insurance Special Enrollment Periods


Clarification on Health Insurance Special Enrollment Periods

Blue Cross and Blue Shield of Illinois (BCBSIL) is providing additional clarification around the qualifying event of gaining/losing a dependent through birth/adoption/fostercare/placement for adoption, which triggers a Special Enrollment opportunity.

The Special Enrollment will trigger a 60-day enrollment period, but the effective dates for enrollees can be different depending on the policyholder’s situation:

Adding a dependent by birth, adoption, or foster care:

If the policyholder is already enrolled in a BCBSIL policy and wishes to make plan changes, the effective date is the first day of the month of the event for all members except the applicable dependent.

Example: If a policyholder wishes to add a newborn (born April 16), she may also elect to change their policy during the Special Enrollment period. If a policy change is made, the newborn’s effective date would begin on the date of birth (April 16) and the policyholder’s previously covered members’ effective date would begin on the first of the month (April 1).

If a Special Enrollment opportunity exists, individuals also have the option to enroll in a policy for the first time for the whole family (IRS-approved tax family) and not just the new dependent. This means that an individual and/or family who may not have had prior coverage will now have the opportunity to enroll in a policy. The whole family can retroactively receive this new policy back to the first day of the month in which the event occurred. The new dependent will be pro-rated.

Example: If a newborn is born on April 16 to a family that is not covered under a health insurance policy, the whole family is now eligible for a Special Enrollment opportunity. The effective date for the enrollees will be April 1 and the newborn’s coverage will be pro-rated to April 16.

If the policyholder is already enrolled in a BCBSIL policy and simply wishes to add the new dependent, the effective date will be the date of the event.

Example: If a newborn is born April 16 to a covered policyholder, and the policyholder does not wish to make any policy changes, the effective date for the newborn will be April 16.

Marriage

In the event of marriage, a Special Enrollment period will allow an effective date of the first day of the month after the marriage.

Example: If a marriage occurs on April 16, the effective date of coverage will be May 1.

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Qualifying EventEnrollment PeriodEffective Date Example
Applicable to both Marketplace and Non-Marketplace (On1 and Off-Exchange) Policies
Gaining/losing a dependent through birth/adoption/foster care/placement for adoption60 days after the eventDate of eventSee Above
Gaining a dependent through marriage60 days after the eventFirst day of the following month after the eventMarried on 1/10

Application on 3/1

Effective date 2/1

Loss of eligible coverage from:

  • Legal separation/divorce
  • Cessation of dependent status (aging out)
    Death
  • Termination or reduction of working hours with employer
60 days after the eventFirst day of the following month after the eventCoverage loss on 2/1

Application on 2/18

Effective date 3/1

Loss of coverage through an HMO due to relocation to a new service area (applicable to both group and individual markets)60 days after the eventFirst day of the following month after the eventRelocation on 3/17

Application on 4/5

Effective date 4/1

Incurs claim that meets or exceeds lifetime limits on all benefits60 days after the eventFirst day of the following month after the eventClaim limit exceeded on 4/17

Application on 4/24

Effective date 5/1

COBRA coverage ends60 days after the eventFirst day of the following month after the eventCoverage ends on 4/1

Application on 4/5

Effective date 5/1

Employer ceases contributions either to subscriber or dependents60 days after the eventFirst day of the following month after the eventContribution stop on 3/2

Application on 3/20

Effective date 4/1

Permanent Move60 days after the eventIf the selection of the plan happens between first and 15th – the effective date is the first of the next month.

If the selection of the plan happens after the 15th – the effective date is the first of the second following month.

Move on 3/3

Application on 3/7

Effective date 4/1

Newly eligible/ineligible for advanced payments of tax credits or change in eligibility from cost-sharing reductions60 days after the eventIf the selection of the plan happens between first and 15th – the effective date is the first of the next month.

If the selection of the plan happens after the 15th – the effective date is the first of the second following month.

Eligible/Ineligible 3/4

Application on 3/17

Effective date 5/1

Qualified Health Plan (QHP) substantially violates a material provision of its contract60 days after the eventIf the selection of the plan happens between first and 15th – the effective date is the first of the next month.

If the selection of the plan happens after the 15th – the effective date is the first of the second following month.

Violation on 1/5

Application on 2/15

Effective date 2/1

Enrollment in QHP is made in error60 days after the eventIf the selection of the plan happens between first and 15th – the effective date is the first of the next month.

If the selection of the plan happens after the 15th – the effective date is the first of the second following month.

Enrollment on 3/1

Application on 3/14

Effective date 4/1

Loss of Minimum Essential Health Coverage (MEC)260 days before and after the eventDate of EventLost MEC on 2/1

Application on 2/27

Effective date 3/1

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