Qualifying Events and Special Enrollment

What is special enrollment?

Employees enrolling in a health plan offered through their job usually can only do so during a set time period each year called “open enrollment”. However, there are certain life events that allow for members to modify their plan. They can change who is on their plan, which plan option they’d like to have, or begin a new plan if they had previously waived coverage.

To be eligible for special enrollment, an employee has to have a qualifying event from this list AND they have to submit a new application and supporting documents within 60 days of the event occurring.

What are qualifying events?

Under HIPAA Special Enrollment and Section 125 Flex Plans, the following events are eligible for special enrollment.

Marital Status Change

  • Marriage
  • Death of spouse
  • Divorce or annulment
  • Legal separation

Number of dependents change

  • Birth
  • Adoption or placement for adoption
  • Death of dependent
  • Newly eligible dependents due to plan design change

HIPAA allows the employee (if they selected employee only coverage) to add a new dependent AND a spouse under the same special enrollment.

Loss of coverage

  • If the employee loses other coverage (ie spouse’s health coverage is terminated or eligibility for Medicare or Medicaid ends)

Dependent Status Change

  • Dependent no longer is eligible as a dependent due to:
    • Age
    • Loss of student status
    • Marriage of dependent child

Employment status

  • Commencement or termination of employment
  • Commencement of, or return from, leave of absence
  • Change from part-time to full-time status (or vice versa)
  • Strike or lockout

Judgment, decree, or order requiring coverage

  • QMCSO (Qualified Medical Child Support Orders)

Change in residence

  • If there is a region-specific plan, employee may qualify to change plan elections due to moving their residence

What documentation is needed?

We need the legal proof that the event took place for each qualifying event. For exmple: for a new marriage, we need a marriage certificate. To add a new baby, we need a birth certificate. For a loss of coverage, we need documentation from the previous employer that coverage is no longer offered.

If you have specific questions on what documents will apply to each qualifying event, call Customer Service at 1-800-662-5851 or email enrollment@emihealth.com.

What is the special enrollment process?

If you are a member with a qualifying event and you want to update your plan information, visit with your HR department and they can walk you through the whole process of applying and providing documented proof of your life event. Make sure to act quickly as special enrollment is allowable only up to 60 days after the event (30 days for a birth of a new child).

If you are a group representative or a broker, the process for special enrollment with EMI Health is based on how you originally submitted the enrollment files.

  • If you are set up with our enrollment portal, you can enter in all the new information through the portal and then send the documentation to enrollment@emihealth.com
  • If you are using a file feed, the spreadsheet document has a place for you to include life events. Simply update the file feed that gets sent each week, and then send the documentation to enrollment@emihealth.com
  • If you use paper applications, scan and send the application and the documentation to enrollment@emihealth.com

Once the special enrollment has been processed, the member will receive new ID cards from EMI Health about 2 weeks later.



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