Special Enrollment Sample Clauses
The Special Enrollment clause allows individuals to enroll in a health insurance plan outside of the standard open enrollment period under specific circumstances. Typically, this applies when a person experiences qualifying life events such as marriage, birth of a child, or loss of other health coverage. By providing a mechanism for timely access to coverage after significant life changes, this clause ensures that individuals are not left uninsured due to events beyond their control.
Special Enrollment a. KFHPWA will allow special enrollment for persons:
1) Who initially declined enrollment when otherwise eligible because such persons had other health care coverage and have had such other coverage terminated due to one of the following events: • Cessation of employer contributions. • Exhaustion of COBRA continuation coverage. • Loss of eligibility, except for loss of eligibility for cause.
2) Who initially declined enrollment when otherwise eligible because such persons had other health care coverage and who have had such other coverage exhausted because such person reached a lifetime maximum limit. KFHPWA or the Group may require confirmation that when initially offered coverage such persons submitted a written statement declining because of other coverage. Application for coverage must be made within 31 days of the termination of previous coverage.
b. KFHPWA will allow special enrollment for individuals who are eligible to be a Subscriber and their Dependents (other than for nonpayment or fraud) in the event one of the following occurs:
1) Divorce or Legal Separation. Application for coverage must be made within 60 days of the divorce/separation.
2) Cessation of Dependent status (reaches maximum age). Application for coverage must be made within 30 days of the cessation of Dependent status.
3) Death of an employee under whose coverage they were a Dependent. Application for coverage must be made within 30 days of the death of an employee.
4) Termination or reduction in the number of hours worked. Application for coverage must be made within 30 days of the termination or reduction in number of hours worked.
5) Leaving the service area of a former plan. Application for coverage must be made within 30 days of leaving the service area of a former plan.
6) Discontinuation of a former plan. Application for coverage must be made within 30 days of the discontinuation of a former plan.
c. KFHPWA will allow special enrollment for individuals who are eligible to be a Subscriber and their Dependents in the event one of the following occurs:
1) Marriage. Application for coverage must be made within 31 days of the date of marriage.
2) Birth. Application for coverage for the Subscriber and Dependents other than the newborn child must be made within 60 days of the date of birth.
3) Adoption or placement for adoption. Application for coverage for the Subscriber and Dependents other than the adopted child must be made within 60 days of the adoption or placement for adopt...
Special Enrollment. Under the circumstances described below, referred to as “qualifying events”, eligible employees and/or eligible dependents may request to enroll in the Plan outside of the initial and annual open enrollment periods, during a special enrollment period.
a. If an eligible employee or eligible dependents declined coverage under the Plan when it was first offered because of other group health plan or insurance coverage and that other coverage is lost due to any of the following qualifying events, the eligible employee or eligible dependents are entitled to a special enrollment period. Loss of other coverage due to an individual’s failure to pay Premiums (including COBRA Premiums) on a timely basis, or termination of coverage for cause (fraud or intentional misrepresentation of material fact) will not trigger a special enrollment period.
i. exhaustion of COBRA continuation coverage;
ii. termination of employment or reduction in hours of employment;
iii. termination of employer Premium contributions;
iv. change in dependent status due to: attainment of limiting age, change in legal custody or legal guardianship, divorce or annulment, or the death of an employee whose employment afforded the dependent coverage;
v. relocation out of an HMO service area;
vi. gaining eligibility for Premium assistance subsidy, or termination of coverage due to loss of eligibility, under Medicaid or CHIP.
b. Upon gaining a new dependent (or dependents) as a result of any of the following qualifying events, a covered employee’s new dependents, or an eligible employee on behalf of himself and his new dependents, may request to enroll during the special enrollment period, providing such dependents are otherwise eligible for coverage: i. marriage;
Special Enrollment. If a Qualified Individual does not enroll during an Annual Open Enrollment Period, he or she may only enroll through the Exchange during a Special Enrollment Period. Except as otherwise provided, during a Special Enrollment Period, a Qualified Individual not currently enrolled in a QHP may enroll in any QHP. In addition, a Qualified Individual currently enrolled a QHP may enroll in another QHP within the same metal level of coverage, or one metal level higher or lower if the same metal level of coverage is not available. A Dependent of a Qualified Individual currently enrolled in a QHP may be added to the Qualified Individual’s current QHP, may enroll with the Qualified Individual in another QHP within the same level of coverage (or one metal level higher or lower if no such QHP is available), or may enroll in any separate QHP. These limitations do not apply to Section 2.6B.1.(i) (plan enrollment for Indians), Section 2.6B.1.(d) (Exchange errors or non-Exchange errors), Section 2.6B.1.(j) (exceptional circumstances), Section 2.6B.1.(m) (victim of domestic violence). For Qualified Individuals using a Special Enrollment Period pursuant to Section 2.6B.1.(i) (plan enrollment for Indians), Section 2.6B.1.(d) (Exchange errors or non-Exchange errors), Section 2.6B.1.(j) (exceptional circumstances), Section 2.6B.1.(m) (victim of domestic violence), the Qualified Individual or the Dependent of a Qualified Individual may enroll in or change to any QHP regardless of whether the Qualified Individual or Dependent of a Qualified Individual is currently enrolled in a QHP.
1. A Qualified Individual may enroll as a Subscriber or Dependent upon the occurrence of one of the following qualifying events:
a) The Qualified Individual or a Dependent:
(1) Loses Minimum Essential Coverage. A loss of Minimum Essential Coverage includes those circumstances described in 45 CFR §155.420 (d)(1)(i). Loss of coverage described herein includes those circumstances described in 45 CFR §155.420 (d)(1)(i). Loss of coverage does not include voluntary termination of coverage or other loss due to: SAMPLE
Special Enrollment. Certain specified events provide You with the opportunity to enroll or disenroll yourself or eligible Dependents from coverage on this Contract. These are special enrollment events. Enrollment or disenrollment must be made during the Special Enrollment Period specified in this Contract. Members who lose this or other coverage because they do not pay their premium or required contributions or lose this or other coverage for cause (such as filing fraudulent Claims or an intentional misrepresentation of a material fact in connection with the Contract) are not special enrollees and have no special enrollment rights. Examples of special enrollment events for this Contract are: Loss of “minimum essential coverage” during the year as a consequence of: Loss of eligibility for coverage under another plan the individual was enrolled in as a result of death, divorce, or loss of dependent status under that health plan; Changing residence to an area not served by the health plan under which the individual was enrolled; Another dental plan stops offering benefits to a certain class of similarly situated individuals of which the individual was a member; Termination of employer contributions towards a person’s coverage under another dental plan in which the individual was enrolled; and Exhaustion of COBRA continuation coverage. An individual requesting special enrollment under this section because of loss of other minimal coverage must request enrollment under this Contract within sixty (60) days after the other coverage ends (or after the employer stops contributing toward the other coverage). If such enrollment is received by a Blue Cross and Blue Shield of Louisiana office within sixty (60) days after loss of other coverage, coverage will become effective on the date other coverage is lost. The request will be denied and coverage will not be available if Blue Cross and Blue Shield of Louisiana does not receive the request for enrollment form within sixty (60) days after the loss of other coverage. A Qualified Health Plan violates a material provision of its contract. The Subscriber gaining a Dependent or becoming a Dependent through marriage, birth, adoption, placement for adoption or mandate granting legal or provisional custody of the child or grandchild. The Special Enrollment Period described in this subparagraph is a period of sixty (60) days and shall begin on the later of the date Dependent coverage is made available or the date of the marriage, birth, adoption,...
Special Enrollment. If you do not enroll when you are first eligible and later want to enroll, you can enroll only during Open Enrollment as described below, unless one of the following is true:
Special Enrollment. During the year, if you have certain qualifying life-changing events, you and your Dependents can enroll for coverage under the Plan through “Special Enrollment.” Special qualifying events, such as birth or adoption of a child, marriage, loss of other qualified health insurance coverage, or changes in eligibility for other public service programs, will trigger a Special Enrollment Period. For guidance on qualifying events, contact the Marketplace or Community Health Options’ Member Services. To take advantage of a Special Enrollment Period, you must complete the enrollment process by visiting the Marketplace to complete information about a change in circumstances or by visiting ▇▇▇.▇▇▇▇▇▇▇▇▇▇▇▇▇.▇▇▇ to complete a “Special Enrollment Period Qualifying Event” web form. If you do not have access to the internet, you may also submit a completed paper Application to Health Options or the Marketplace, as applicable. You must complete the enrollment process for new Dependent coverage within 60 days of the qualifying event. If you become a Member or add new Dependents through a Special Enrollment Period, the effective date of coverage depends on the type and date of event, as well as when Community Health Options® (“Health Options”) receives premium payment and the completed enrollment information. You will be notified of the effective date of coverage.
Special Enrollment. If a Qualified Individual does not enroll during an Annual Open Enrollment Period, he or she may only enroll through the Exchange during a Special Enrollment Period.
1. A Qualified Individual may enroll as a Subscriber or Dependent upon the occurrence of one of the following qualifying events:
a) The Qualified Individual or a Dependent:
(1) Loses Minimum Essential Coverage. A loss of Minimum Essential Coverage includes those circumstances described in 26 CFR 54.9801-6(a)(3)(i) through (iii). Loss of coverage described herein includes those circumstances described in 26 CFR 54.9801-6(a)(3)(i) through (iii) and in paragraphs (d)(1)(ii) through (iv) of 45 CFR §155.420. Loss of coverage does not include voluntary termination of coverage or other loss due to:
(a) Failure to pay premiums on a timely basis, including COBRA premiums prior to the expiration of COBRA coverage; or
(b) Situations allowing for a Rescission.
(2) Is enrolled in any non-Calendar Year health insurance policy even if the Qualified Individual or his or her Dependent has the option to renew non-Calendar Year health insurance policy. The date of the loss of coverage is the last day of the non-Calendar Year policy year.
(3) Loses pregnancy-related coverage described in 1902(a)(10)(A)(i)(IV) and (a)(10)(A)(ii)(IX) of the Social Security Act (42 U.S.C. 1396a(a)(10)(A)(i)(IV), (a)(10)(A)(ii)(IX)). The date of the loss of coverage is the last day the consumer would have pregnancy-related coverage; or
(4) Loses medically needy coverage as described under section 1902(a)(10)(C) of the Social Security Act only once per Calendar Year. The date of the loss of coverage is the last day the consumer would have medically needy coverage.
(5) Loses a dependent or is no longer considered a dependent through divorce or legal separation or if the Subscriber or his or her Dependent dies.
b) A Qualified Individual gains, or becomes, a Dependent through marriage, birth, adoption, placement for adoption, grant of court or testamentary guardianship, child support order (MCSO) or other court order, or placement of a child for ▇▇▇▇▇▇ care. The ▇▇▇▇▇▇ child is not eligible for coverage under this Agreement. SAMPLE
c) The Qualified Individual or his or her Dependent was not previously a citizen, national, or lawfully present in the United States and gains such status.
d) The Qualified Individual’s or his or her Dependent’s enrollment in another Qualified Health Plan or non-enrollment is unintentional, inadvertent, or err...
Special Enrollment. You can only enroll during the annual open enrollment described above, unless one of the following is true. You:
Special Enrollment. Outside of the annual open enrollment period, certain “triggering events” allow a Contractholder’s eligible dependents, or an eligible individual on behalf of himself and his eligible dependents, to enroll in the Plan during a special enrollment period (SEP). In order for coverage to become effective, any application or enrollment forms we require, along with proof of the triggering event (e.g. certificate of marriage, written evidence of adoption or copy of a court order), must be submitted to us within the timeframes described below. If not received within the required timeframes, coverage will not become effective, and enrollment will not be available until the next annual open enrollment period.
Special Enrollment. Certain specified events provide You with the opportunity to enroll or disenroll yourself or eligible Dependents from coverage on this Contract. These are special enrollment events. Enrollment or disenrollment must be made during the Special Enrollment Period specified in this Contract. Members who lose this or other coverage because they do not pay their premium or required contributions or lose this or other coverage for cause (such as filing fraudulent Claims or an intentional misrepresentation of a material fact in connection with the Contract) are not special enrollees and have no special enrollment rights.
1. Examples of special enrollment events for all this Contracts are:
a. Loss of “minimum essential coverage” during the year as a consequence of:
(1) Loss of eligibility for coverage under another plan the individual was enrolled in as a result of death, divorce, or loss of dependent status under that health plan;
(2) Changing residence to an area not served by the health plan under which the individual was enrolled;
(3) Another dental plan stops offering benefits to a certain class of similarly situated individuals of which the individual was a member;
(4) Termination of employer contributions towards a person’s coverage under another dental plan in which the individual was enrolled; and