Are all qualifying life events created equal?

April 13, 2016 12:06 PM

My understanding was that a "qualifying life event" - new job for you or spouse, you or spouse divorce/die, you or spouse give birth to or adopt a child - opened a free open enrollment period for you, spouse, and child, wherein you could do things such as decline insurance from one spouse's plan and both enroll on the other plan, and generally make whatever health insurance changes you wanted to. My HR rep told me that this is not always the case for birth/adoption of a child specifically - more inside.

My spouse and I are both covered under my insurance, which costs less than his plan and has pretty great benefits in general, especially for maternity/birth. When I give birth to a child, I'm not sure if I will continue to work at my same job or might take time off. I'd like to pre-emptively switch all three of us to my spouse's plan under the "qualifying life event" open enrollment within the 30 days after childbirth. Assume for the purpose of the question that waiting for the general employer open enrollment won't work, timing wise.

My HR rep told me that when you give birth to a child, you can't change coverage for the adults, and can only add the child to your plan. Is this true? I can't find any language on a government website that singles out birth/adoption as a special qualifying event under which you can't change whatever you want to, and I'm assuming this a matter of federal law under the ACA so it wouldn't matter what state/employer policies are in this case.

posted by permiechickie to Law & Government (10 answers total)

Best answer: You can't pre-empt it, unfortunately. The open enrollment is for the new child. If you decide to quit your job, that is a new "qualifying life event" and you can change your own coverage then. Besides, if your plan costs less and has great benefits, it sounds like it would benefit you to stay on it anyway while you still can.
posted by jillithd at 12:13 PM on April 13, 2016 [4 favorites]

You need to consult your summary plan document. This is, generally speaking, a matter of federal law as you say, but under Section 125 of the IRS code. The law does not require a health plan to allow mid year changes; these rules are governed by the plan document.
posted by pecanpies at 12:31 PM on April 13, 2016

Best answer: To add a little more: it's my understanding from the guidelines the IRS has put forth that any mid year change in coverage must be consistent with the qualifying event. So, dropping coverage altogether after the birth of a baby likely wouldn't be considered "consistent," only adding the baby would be. I'm not an attorney, and I don't have your plan document, but it's likely that your HR person is correct.
posted by pecanpies at 12:33 PM on April 13, 2016 [1 favorite]

Shouldn't your spouse be the one consulting their HR/benefits department to see if enrollment is possible upon childbirth? Also, what jillithd said: Just keep the family on your plan until you leave, which should allow all of you to jump onto your spouse's plan. (I am not an expert, etc, so your spouse should check on this with HR)
posted by Mr. Big Business at 12:45 PM on April 13, 2016

Mr. B, the spouse would likely be able to enroll, but the OP also likely wouldn't be able to cancel coverage. So they'd have double coverage.
posted by pecanpies at 12:48 PM on April 13, 2016

I nth the suggestion to examine your Summary Plan Document (your HR rep should be able to provide it to you) and to be aware that, if and when you leave your employer, that will be another "qualifying life event" that will give you the opportunity to change plans.

One other idea: if you haven't already, you should definitely look into CHIP (Children's Health Insurance Program). You can see if your child qualifies and, if so, enroll your child in CHIP while you and your spouse stay on your current plans. If you qualify and depending on your state, it might turn out to be a better deal and/or better coverage for your kid than your employer plan.
posted by ourobouros at 12:53 PM on April 13, 2016

Best answer: Having done some work on healthcare enrollment from the IT side of things:

Some employers might allow the addition of a spouse, and not just a child, when a child is born. That would be a question for your spouse's HR department. If he's able to add you, you would possibly be able to drop your employers healthcare -- being covered by another plan is also an eligible event for a change of coverage, as far as I know.

The likely scenario is that both are going to be fairly strict. So on the birth of your child, the baby is added to the spouse's plan, and if you later terminate your employment, you are added to his plan at that time.
posted by mikeh at 12:53 PM on April 13, 2016 [2 favorites]

Response by poster: Thanks everyone - I will look into the summary plan document and have my husband talk to his company's HR. The reason I wanted to pre-emptively switch is that if I take FMLA and don't return back to work immediately after, I'm on the hook for the employer health-care premiums (ouch), which I didn't know when I elected to put my spouse and I on my insurance.
posted by permiechickie at 1:04 PM on April 13, 2016

FMLA leave is also considered a qualifying event by some plans. I didn't think of that til you mentioned it. Definitely check your SPD - you may be able to drop coverage when your FMLA leave starts. If this happens to coincide with your child's birth, great, but I realize it may not - I know many moms need to start their leave prior to delivery, sometimes well in advance depending on the circumstances.
posted by pecanpies at 2:30 PM on April 13, 2016 [1 favorite]

In terms of birth - switching can cause alot of headaches if you do so in the last trimester. You may have a different network of hospitals and coverage which could throw your neonatal care plan kilter, and that is the last thing you want to happen to you. You may want to look to see if one of the insurances has better coverage for complications, as a NICU stay can be long.
posted by AlexiaSky at 7:23 PM on April 13, 2016