Common use of Special Enrollment Periods Clause in Contracts

Special Enrollment Periods. A special enrollment period occurs when a person experiences a triggering event. If You experience one of the triggering events listed below, You can enroll for coverage and enroll Your eligible Dependent(s) during a Special Enrollment Period instead of waiting for the next Annual Open Enrollment Period. Triggering events for a special enrollment period are: An eligible individual, and any dependent(s), loses his or her minimum essential coverage; or • An eligible individual and his or her dependent(s) lose employer-sponsored health plan coverage due to voluntary or involuntary termination of employment for reasons other than misconduct, or due to a reduction in work hours; or • An eligible individual gaining or becoming a dependent through marriage, birth, adoption or placement of adoption; or • An eligible dependent spouse or child loses coverage under an employer-sponsored health plan due to employee’s becoming entitled to Medicare, divorce, legal separation of the covered employee, and death of the covered employee; • An eligible individual loses his or her dependent child status under a parent’s employer-sponsored health plan; or • An individual who was not previously a citizen, national or lawfully present individual gains such status, is only applicable to the marketplace; or • An eligible individual’s enrollment or non-enrollment in a qualified health plan is unintentional, inadvertent, or erroneous and as the result of the error, misrepresentation, or inaction of an officer, employee or agent of the state marketplace, or of the Department of Health and Human Services (HHS), or its instrumentalities as determined by the marketplace. In such cases, the marketplace may take such action as may be necessary to correct or eliminate the effects of such error, misrepresentation or action; or • An eligible individual adequately demonstrates to the marketplace that the qualified health plan in which he or she is enrolled substantially violated a material provision of its contract in relation to that person; or • An eligible individual is determined newly eligible or newly ineligible for advance payments of the premium tax credit or has a change in eligibility for cost-sharing reductions, regardless of whether such individual is already enrolled in a qualified health plan. The marketplace must permit individuals whose existing coverage through an eligible employer-sponsored plan will no longer be affordable or provide minimum value for his or her employer’s upcoming plan year to access this special enrollment period prior to the end of his or her coverage through such eligible employer-sponsored plan; or • An eligible individual gains access to new qualified health plans as a result of a permanent move (including a move outside the service area of the individual’s current plan); or • An Indian, as defined by section 4 of the Indian Health Care Improvement Act, may enroll in a qualified health plan or change from one qualified health plan to another one time per month; • An eligible individual or enrollee demonstrates to the marketplace, in accordance with guidelines issued by HHS, that he or she meets other exceptional circumstances as the marketplace may provide. Triggering events do not include loss of coverage due to failure to make premium payments on a timely basis, including COBRA premiums prior to expiration of COBRA coverage; and situations allowing for a rescission as specified in 45 CFR 147.128. The special enrollment period begins on the date the triggering event occurs, and ends on the 61st day following the triggering event. Persons who enroll during a special enrollment period will have coverage effective dates determined as follows): • In the case of birth, adoption, placement for adoption, or placement in xxxxxx care, coverage is effective for a qualified individual or enrollee on the date of birth, adoption, placement for adoption, or placement in xxxxxx care. Under PPACA special enrollment period guidelines the qualified individual or enrollee may elect a coverage effective date of the first day of the month following the date of the event, OR elect a regular effective date. If the qualified Individual or enrollee does not elect a delayed effective date then the “default” will be the date of birth for a newborn, adoption, or placement in the home for an adopted or xxxxxx child. • In the case of marriage, or in the case where a qualified individual loses minimum essential coverage, coverage is effective for a qualified individual or enrollee on the first day of the following month. For all other triggering events the effective dates are: • For an application made between the first and the 15th day of any month, the effective date of coverage will be the first day of the following month; • For an application made between the 16th and the last day of the month, the effective date of coverage will be the first day of the second following month.

Special Enrollment Periods. A special enrollment period occurs when a person experiences a triggering event. If You experience one of the triggering events listed below, You can enroll for coverage and enroll Your eligible Dependent(s) during a Special Enrollment Period instead of waiting for the next Annual Open Enrollment Period. Triggering events for a special enrollment period are:  An eligible individual, and any dependent(s), loses his or her minimum essential coverage; or •  An eligible individual and his or her dependent(s) lose employer-sponsored health plan coverage due to voluntary or involuntary termination of employment for reasons other than misconduct, or due to a reduction in work hours; or •  An eligible individual gaining or becoming a dependent through marriage, birth, adoption or placement of adoption; or •  An eligible dependent spouse or child loses coverage under an employer-sponsored health plan due to employee’s becoming entitled to Medicare, divorce, legal separation of the covered employee, and death of the covered employee; •  An eligible individual loses his or her dependent child status under a parent’s employer-employer- sponsored health plan; or •  An individual who was not previously a citizen, national or lawfully present individual gains such status, is only applicable to the marketplace; or •  An eligible individual’s enrollment or non-enrollment in a qualified health plan is unintentional, inadvertent, or erroneous and as the result of the error, misrepresentation, or inaction of an officer, employee or agent of the state marketplace, or of the Department of Health and Human Services (HHS), or its instrumentalities as determined by the marketplace. In such cases, the marketplace may take such action as may be necessary to correct or eliminate the effects of such error, misrepresentation or action; or •  An eligible individual adequately demonstrates to the marketplace that the qualified health plan in which he or she is enrolled substantially violated a material provision of its contract in relation to that person; or •  An eligible individual is determined newly eligible or newly ineligible for advance payments of the premium tax credit or has a change in eligibility for cost-sharing reductions, regardless of whether such individual is already enrolled in a qualified health plan. The marketplace must permit individuals whose existing coverage through an eligible employer-sponsored plan will no longer be affordable or provide minimum value for his or her employer’s upcoming plan year to access this special enrollment period prior to the end of his or her coverage through such eligible employer-sponsored plan; or •  An eligible individual gains access to new qualified health plans as a result of a permanent move (including a move outside the service area of the individual’s current plan); or •  An Indian, as defined by section 4 of the Indian Health Care Improvement Act, may enroll in a qualified health plan or change from one qualified health plan to another one time per month; •  An eligible individual or enrollee demonstrates to the marketplace, in accordance with guidelines issued by HHS, that he or she meets other exceptional circumstances as the marketplace may provide. Triggering events do not include loss of coverage due to failure to make premium payments on a timely basis, including COBRA premiums prior to expiration of COBRA coverage; and situations allowing for a rescission as specified in 45 CFR 147.128. The special enrollment period begins on the date the triggering event occurs, and ends on the 61st day following the triggering event. Persons who enroll during a special enrollment period will have coverage effective dates determined as follows): •  In the case of birth, adoption, placement for adoption, or placement in xxxxxx care, coverage is effective for a qualified individual or enrollee on the date of birth, adoption, placement for adoption, or placement in xxxxxx care. Under PPACA special enrollment period guidelines the qualified individual or enrollee may elect a coverage effective date of the first day of the month following the date of the event, OR elect a regular effective date. If the qualified Individual or enrollee does not elect a delayed effective date then the “default” will be the date of birth for a newborn, adoption, or placement in the home for an adopted or xxxxxx child. •  In the case of marriage, or in the case where a qualified individual loses minimum essential coverage, coverage is effective for a qualified individual or enrollee on the first day of the following month. For all other triggering events the effective dates are: •  For an application made between the first and the 15th day of any month, the effective date of coverage will be the first day of the following month; •  For an application made between the 16th and the last day of the month, the effective date of coverage will be the first day of the second following month.

Special Enrollment Periods. A special enrollment period occurs when a person experiences a triggering event. If You experience one of the triggering events listed belowa Triggering Event, You may qualify for a Special Enrollment Period, during which You can enroll for coverage and enroll Your eligible Dependent(s) during a Special Enrollment Period ), instead of waiting for the next Annual Open Enrollment Period. Triggering events Events for a special enrollment period areSpecial Enrollment Period can be categorized into the following groups: An eligible individual• Loss of qualifying health coverage; • Change in household size; • Change in primary place of living; • Change in eligibility for Exchange coverage or help paying for coverage; • Enrollment or plan error; • Otherqualifyingchanges. Note that failure to pay premiums, and any dependent(s), loses his or her coverage that is lost on the basis of fraud or an intentional misrepresentation of material fact is never a triggering event. “Loss of qualifying health coverage” includes: □ You or Your dependent has lost minimum essential coverage during or at the end of the coverage year, including but not limited to Medicaid, CHIP, qualifyingemployersponsoredcoverage □ It is the end of the Plan Year for Your non-Plan Year employer- sponsored coverage; □ Your COBRA coverage has been exhausted; □ You are no longer eligible to be covered as a dependent due to reaching the limiting age; □ You or • An eligible individual and his or her dependent(s) lose Your dependent loses employer-sponsored health plan coverage due to because of voluntary or involuntary termination of employment or a reduction in work hours, for reasons other than misconduct, or due to a reduction in work hours; or • An eligible individual gaining or becoming a dependent through marriage□ You, birth, adoption or placement of adoption; or • An eligible dependent Your spouse or child loses coverage under an employer-sponsored health plan due to the employee’s becoming entitled to Medicare, divorce, divorce or legal separation of the covered employee, and or death of the covered employee. “Change in household size” includes: □ You gain a dependent or become a dependent through marriage; • An eligible individual loses his o Note that one spouse must have had minimum essential coverage for one or her dependent child status under a parent’s employer-sponsored health plan; or • An individual who was not previously a citizen, national or lawfully present individual gains such status, is only applicable more days in the 60 days prior to the marketplacemarriage, unless that spouse was living in a foreign country or US territory, or is a member of a federally recognized tribe or a shareholder in an Alaska Native Corporation. □ You gain a dependent or become a dependent through birth, adoption, placement for adoption, or placement in xxxxxx care, or through a child support order or other court order; □ You lose a dependent due to divorce, legal separation, or death. “Change in primary place of living” includes: □ You or Your dependent gain access to new plans as a result of a permanent move. o Note that You or Your dependent must have had minimum essential coverage for one or more days in the 60 days prior to the marriage, unless You or Your dependent were living in a foreign country or US territory, or is a member of a federally recognized tribe or a shareholder in an Alaska Native Corporation. o Moving solely for medical treatment or vacation are not valid Triggering Events. “Change in eligibility for Exchange coverage or help paying for coverage” includes: □ You or Your dependent are determined newly eligible or newly ineligible for advance payments of the premium tax credit (APTC) or has a change in eligibility for cost-sharing reductions (CSR); “Enrollment or plan error” includes: • An eligible individualYou or Your dependent’s enrollment or non-enrollment in a qualified health plan Plan is unintentional, inadvertent, or erroneous and as is the result of the error, misrepresentation, misconduct, or inaction of an officer, employee or agent of the state marketplaceExchange, or of the Department of Health and Human Services (HHS), its instrumentalities, or its instrumentalities as determined by the marketplace. In such cases, the marketplace may take such action as may be necessary to correct a non-Exchange entity providing enrollment assistance or eliminate the effects conducting enrollment activities; • You or Your dependent’s enrollment or non-enrollment in a Plan or inaccurate eligibility determination is a result of such a technical error, misrepresentation ; □ You or action; or • An eligible individual Your dependent adequately demonstrates demonstrate to the marketplace Exchange or State Regulatory Agency, that the qualified health plan in which he or she is enrolled substantially violated a material provision of its contract in relation to that personthe enrolle; □ You or • An eligible individual is Your dependent applied for coverage through the Exchange either during the annual open enrollment period or due to a qualifying event or at the State Medicaid or CHIP agency during the annual open enrollment period, and are determined newly eligible or newly ineligible for advance payments Medicaid or CHIP by the State Medicaid or CHIP agency either after Open Enrollment has ended or more than 60 days after the qualifyingevent. “Other qualifying changes”includes: □ You or Your dependent are survivors of the premium tax credit domestic abuse or has a change in eligibility for cost-sharing reductions, regardless of whether such individual is already enrolled in a qualified health plan. The marketplace must permit individuals whose existing coverage through an eligible employer-sponsored plan will no longer be affordable or provide minimum value for his or her employer’s upcoming plan year to access this special enrollment period prior to the end of his or her coverage through such eligible employer-sponsored planspousal abandonment; or • An eligible individual gains access to new qualified health plans as a result of a permanent move (including a move outside the service area of the individual’s current plan); or • An Indian, as defined by section 4 of the Indian Health Care Improvement Act, may enroll in a qualified health plan or change from one qualified health plan to another one time per month; • An eligible individual or enrollee demonstrates to the marketplace, in accordance with guidelines issued by HHS, that he or she meets other exceptional circumstances as the marketplace may provide. Triggering events Events do not include loss of coverage due to failure to make premium Premium payments on a timely basis, including . This includes COBRA premiums Premiums prior to the expiration of Your COBRA coverage; coverage and situations allowing for a rescission as specified in 45 CFR 147.128under federal and state law. The special enrollment period begins Special Enrollment Periods begin on the date the triggering event Triggering Event occurs, and ends end on the 61st day following afterwards. Note that for “Loss of qualifying health coverage” and “Change in primary place of living” categories of Triggering Event, you may also submit an application in the triggering 60 days leading up to the event. Persons who enroll during a special enrollment period Special Enrollment Period will have their coverage effective dates Effective Dates determined as follows): : • In the case of birth, adoption, placement for adoption, or placement in xxxxxx care, or a child support order or other court order, Your coverage is effective for a qualified individual or enrollee on the date of birth, adoption, placement for adoption, or placement in xxxxxx care. Under PPACA special enrollment period guidelines the qualified individual or enrollee may elect a coverage effective date of the first day of the month following the date of the event, OR elect a regular effective date. If the qualified Individual or enrollee does not elect a delayed effective date then the “default” will be the date of birth for a newborn, adoption, or placement in the home for an adopted or xxxxxx child. ; • In the case of marriage, or in the case where a qualified individual loses You lose minimum essential coverage, coverage is effective for a qualified individual or enrollee on the first day of the following month. For • In the case where the application is submitted before the event, coverage is effective the first day of the month following the event. In all other triggering events cases, the effective dates areEffective Dates are as follows: • For an application made between the first and the 15th day of any month, the effective date Effective Date of coverage will be the first day of the following month; or • For an application made between the 16th and the last day of the month, the effective date Effective Date of coverage will be the first day of the second following month. Open Enrollment Eligible employees or dependents, who do not enroll for coverage under the policy following their eligibility date or special enrollment date, have an opportunity to enroll for coverage during the open enrollment period. The open enrollment period is also the opportunity for late applicants to enroll for coverage. Eligible employees or dependents, including late applicants, must request enrollment during the open enrollment period. If enrollment is requested after the open enrollment period, the employee or dependent must wait to enroll for coverage during the next open enrollment period, unless they become eligible for special enrollment as specified in the "Special enrollment" provision.

Special Enrollment Periods. A special enrollment period occurs when a person experiences a triggering event. If You experience one of the triggering events listed below, You can enroll for coverage and enroll Your eligible Dependent(s) during a Special Enrollment Period instead of waiting for the next Annual Open Enrollment Period. Triggering events for a special enrollment period are: ▪ An eligible individual, and any dependent(s), loses his or her minimum essential coverage; or • ▪ An eligible individual and his or her dependent(s) lose employer-sponsored health plan coverage due to voluntary or involuntary termination of employment for reasons other than misconduct, or due to a reduction in work hours; or • ▪ An eligible individual gaining or becoming a dependent through marriage, birth, adoption or placement of adoption; or • ▪ An eligible dependent spouse or child loses coverage under an employer-sponsored health plan due to employee’s becoming entitled to Medicare, divorce, legal separation of the covered employee, and death of the covered employee; • ▪ An eligible individual loses his or her dependent child status under a parent’s employer-employer- sponsored health plan; or • ▪ An individual who was not previously a citizen, national or lawfully present individual gains such status, is only applicable to the marketplace; or • ▪ An eligible individual’s enrollment or non-enrollment in a qualified health plan is unintentional, inadvertent, or erroneous and as the result of the error, misrepresentation, or inaction of an officer, employee or agent of the state marketplace, or of the Department of Health and Human Services (HHS), or its instrumentalities as determined by the marketplace. In such cases, the marketplace may take such action as may be necessary to correct or eliminate the effects of such error, misrepresentation or action; or • ▪ An eligible individual adequately demonstrates to the marketplace that the qualified health plan in which he or she is enrolled substantially violated a material provision of its contract in relation to that person; or • ▪ An eligible individual is determined newly eligible or newly ineligible for advance payments of the premium tax credit or has a change in eligibility for cost-sharing reductions, regardless of whether such individual is already enrolled in a qualified health plan. The marketplace must permit individuals whose existing coverage through an eligible employer-sponsored plan will no longer be affordable or provide minimum value for his or her employer’s upcoming plan year to access this special enrollment period prior to the end of his or her coverage through such eligible employer-sponsored plan; or • ▪ An eligible individual gains access to new qualified health plans as a result of a permanent move (including a move outside the service area of the individual’s current plan); or • ▪ An Indian, as defined by section 4 of the Indian Health Care Improvement Act, may enroll in a qualified health plan or change from one qualified health plan to another one time per month; • ▪ An eligible individual or enrollee demonstrates to the marketplace, in accordance with guidelines issued by HHS, that he or she meets other exceptional circumstances as the marketplace may provide. Triggering events do not include loss of coverage due to failure to make premium payments on a timely basis, including COBRA premiums prior to expiration of COBRA coverage; and situations allowing for a rescission as specified in 45 CFR 147.128. The special enrollment period begins on the date the triggering event occurs, and ends on the 61st day following the triggering event. Persons who enroll during a special enrollment period will have coverage effective dates determined as follows): • ▪ In the case of birth, adoption, placement for adoption, or placement in xxxxxx care, coverage is effective for a qualified individual or enrollee on the date of birth, adoption, placement for adoption, or placement in xxxxxx care. Under PPACA special enrollment period guidelines the qualified individual or enrollee may elect a coverage effective date of the first day of the month following the date of the event, OR elect a regular effective date. If the qualified Individual or enrollee does not elect a delayed effective date then the “default” will be the date of birth for a newborn, adoption, or placement in the home for an adopted or xxxxxx child. • ▪ In the case of marriage, or in the case where a qualified individual loses minimum essential coverage, coverage is effective for a qualified individual or enrollee on the first day of the following month. For all other triggering events the effective dates are: • ▪ For an application made between the first and the 15th day of any month, the effective date of coverage will be the first day of the following month; • ▪ For an application made between the 16th and the last day of the month, the effective date of coverage will be the first day of the second following month.