Qualifying Events are exceptions to allow employees and their dependents to be added to health coverage during times other than Open Enrollment.
Examples of Special Qualifying events are death of a spouse, divorce, legal separation, loss of eligibility, loss of coverage due to exhausting lifetime benefit maximum, loss of TennCare, termination of spouse’s employment, employer eliminated total contribution to spouse’s or dependent’s insurance, spouse’s work hours have been reduced causing loss of eligibility.
Reminders when processing Qualifying Events (QE).
- Request for coverage must be submitted within 60 days of the occurrence of the qualifying event.
- Documentation for verification of the event is required.
- The earliest effective date allowed for coverage under this plan is the first day of the month following the date that a complete enrollment request is received at Benefits Administration.
Please remember: The written documentation from an employer, former employer, insurance company, or former insurance company on company letterhead must list:
- names of covered participants
- dates of coverage including coverage at the time coverage in this plan was declined- (either new hire or most recent annual enrollment period)
- types of coverage (medical, dental, vision)
- each participant that lost eligibility for coverage (these are the only participants that may be enrolled due to the loss)
- the date of loss of eligibility to continue coverage
- the reason why eligibility for coverage was lost
Even though PD 2.06(A)(5) indicates that the effective date of coverage shall be the first day of the first calendar month after the date BA receives the request for special enrollment, that is only true if the person making the request has had a SQE, meaning that they have satisfied all the special enrollment conditions in 2.06(A)(1), including experiencing a loss of eligibility for other health coverage. If a member has a loss of coverage mid month but submits all documentation prior to the loss, the first day coverage can be the first of the month following the loss of coverage as the coverage cannot begin prior to the loss of coverage. ( EX: coverage is set to end on 8/15, member submits all documents on 7/20, coverage can only start on 9/1 since the event that is allowing the special enrollment is on 8/15)