Qualifying Event

joimack · October 2003

[font size="1" color="#FF0000"]LAST EDITED ON 10-28-03 AT 03:57PM (CST)[/font][p]We have an employee who was covered under his wife's medical insurance. At her open enrollment she chose to drop his coverage due to increased premiums. Is this loss of coverage a qualifying event for our employee? Our insurance administrator is telling us our employee has to wait until our open enrollment. This means our employee is without any coverage for 6 months.

Pearce · October 2003

Your employee is likely just going to have to wait for your open enrollment. Your healthplan can adhere to the strictest interpretation of the HIPAA Special Enrollment regulations which would not consider this a loss of coverage due to loss of eligibility for coverage. When his wife dropped his coverage presumably he was still eligible for the coverage.

Balloonman · October 2003

He can always take cobra from his wife's plan! I had this come up, fortunately my person asked if they could just pick it up...........check and they have to wait until open enrollment.
My $0.02 worth.
DJ The Balloonman

cthr · October 2003

That's interesting, my husband's company does open enrollment for Oct 1, my company for Jan 1. We had coverage thru my employer, but dropped when we changed carriers, because there was no out of network coverage for his daughter who is out of state. His company only required a letter from my employer stating that effective xx/xx/xx, we were no longer covered by my employer and we were able to pick up outside of the open enrollment period.

LindaS · October 2003

I would agree. The voluntary dropping of coverage would not be considered a qualifying event.

irenesmsaclaims · October 2003

The husband cannot get COBRA from the wife's plan, since there is no qualifying event for COBRA for him. Voluntary dropping other coverage does not give rise to a special enrollment (not qualifying event, that's COBRA terminology) for him to get on your plan. Sometimes using terms from other rules makes something which is complex even more confusing!!

LindaS · October 2003

I agree that the husband would not qualify for COBRA under the wife's plan since voluntarily dropping coverage is not a qualifying event. If your plan does not allow adding the husband to the coverage I would recommend having the wife find out if she can add him back to her plan - may not do any good but it's worth a try.

jmcaa · October 2003

[font size="1" color="#FF0000"]LAST EDITED ON 10-30-03 AT 09:15AM (CST)[/font][p]You can check out this link regarding section 125 plans and qualifying events.

[url]http://www.irs.gov/pub/irs-utl/tres_reg-1125-4.pdf[/url]

I would let him join the health plan due to the increase in the cost of his spouse's coverage.

Pearce · October 2003

The cost of coverage changes allowed under Section 125 may or may not apply. The underlying plan in this case is the health plan and if it abides by the HIPAA Special Enrollment regulations in the strictest since, the health plan would not allow entry because of a cost of coverage change that happened in another employer's plan. An increase in the cost of coverage in that other plan is not a "loss of coverage" requiring Special Enrollment.

Nat · October 2003

I agree. We just went through this with some of our employees on our plan. Excessive increase in premiums is considered a qualifying event so the employee should not have to wait until open enrollment.

irenesmsaclaims · October 2003

I hope we're not confusing the original poster. Pearce is right, one of the status changes required in order to change elections in a Section 125 plan is a change in premium. This does not carry over to a medical plan, for special enrollment events. These are two different things. Neither is a "qualifying event".

Qualifying Event

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