What qualifies as life changing?

July 23, 2007 1:17 PM

Health Insurance Filter: Life-changing events - I need some clarification on a life-changing event and what qualifies...

My wife is having a baby soon and when she does I'd like to move her off our work group plan to cheaper individual health insurance. The baby is a life-changing event - but only to add the baby. I can't take her off until open enrollment in February.

I was told that gaining or losing a job is also considered a life-changing event. She quit her job back in May to stay home full time and grow the baby.

Can she:

A) Claim in September that she has quit her job because of the baby and qualify as life-changing? What's the window?

B) Do freelance work that is a new job for her and claim this as a new job so I can remove her from the group insurance?

C) None of the above, suck it up?

Just incase it's important, United Healthcare is the insurance company.

Thanks for the advice!

posted by jimmy0x52 to health & fitness (12 comments total)

I am by no means an expert, but I believe a birth in the family qualifies (at least, here in Ohio). The best answer this will come from your HR department though.
posted by TheDukeofLancaster at 1:21 PM on July 23, 2007

Well, some searching seems to confirm this qualifies...


Question 2
Question 21
Way down the list, search for "When can a postdoc add a dependent?"
posted by TheDukeofLancaster at 1:33 PM on July 23, 2007

Wait. I'm confused. You and your wife are on your employer's group medical plan and you want to remove her from your plan and get her an individual plan because it's cheaper? Without knowing specifics, this doesn't sound like a very good idea.

So, the basic deal is that your change in election has to be consistent with the qualifying event (which is the phrase you're looking for, by the way). While your wife quitting her job is a qualifying event, the change in election (removing her from the plan) is not consistent with that change, so I don't think it would fly.

The section 125 plan which lets your medical contributions be collected pre-tax is the sticking point here. The medical insurer has no problem with you removing anyone you want whenever you want (as long as you're not breaking a ruling in a divorce decree, etc.), but you'll still have to have contributions deducted in the same way until open enrollment in February.

I think C it is. Congratulations on the baby!
posted by MarkAnd at 2:16 PM on July 23, 2007

Is there a reason you don't want to ask your HR or Benefits department these questions? Because sometimes the individual company you work for changes the flavor of the nature of the benefit (for instance, when enrollment is or what the grace period is for qualifying life events, etc.).

So no clearcut answers but a few things to keep in mind:
1) Make sure you understand the implications of any route you pursue wherein it looks like your wife did not have coverage--even if only "technically" or "on paper" in the past--for 30-60 days. Many insurance companies view such a gap as a reason to deny or reduce coverage for a certain amount of time (often a year), or to increase premiums.
2) If eventually your wife will be with a different insurance company (or sometimes even a different plan), there may be some impact on her ability to get information for the baby unless you fill out some extra forms (HIPAA releases). This happened to me and was infuriating. Luckily it wasn't during a medical emergency. Also, the company you work for may add a layer of administrivia if your wife isn't on the same plan. I have had to go through my husband to update personal information about Baby Cocoa. Not a deal-breaker, but when you have a newborn any additional bureacracy is a pain in the neck. Good luck and congratulations!
posted by cocoagirl at 2:30 PM on July 23, 2007

Just a note of caution--if I'm reading you correctly, you're planning on dropping her from the "family" policy you currently have through work (a group plan) in order to insure her through the individual market. Are you *sure* that will be cheaper? Usually, group rates (that is, the ones that spread risk among a group of people, like all your co-workers, who tend to be a healthier bunch than the people seeking insurance through the open market) are cheaper than individual rates.

If you're pretty sure that it's cheaper to forgo group insurance in favor of buying it on the open market, make sure that she applies and is approved for a policy before dropping her from your work insurance. Insurance companies won't just insure anyone willing to pay, and a woman of childbearing age who is a SAHM might ring all sorts of alarms as being a bad insurance risk (because she may have more children, and that's a potentially very expensive claim for insurance companies to cover). You don't want to drop her from your insurance just to find out she's uninsurable in the open market--you wouldn't be able to add her back on to your insurance until open season again.

Your HR department is in charge of who qualifies as having a "life changing event," and you'd have to go through them (not the insurance company directly) anyway to drop your wife from your insurance, so you should ask HR directly about what would qualify to remove her from your work plan.
posted by iminurmefi at 2:36 PM on July 23, 2007

I'm right there with the others who are puzzled that the individual plan is cheaper -- the monthly premiums may be cheaper, but is the coverage the same or better? What will your out of pocket costs be on the new plan? In the post-partum period she may need a significant amount of medical support - will the new plan cover this in the same way the old plan did?

"lower premiums" does not always equal "a better value"
posted by anastasiav at 3:13 PM on July 23, 2007

I've asked HR - and the response was not as detailed as I would have liked (which is why I go to the MeFites).

Thanks for all the help. I understand the implications. The policy we have at work is a group policy in the sense that it's the group of people employed here and their spouses/dependants. Therefore, when I add her, I pay full premium (which is like a 10% pay decrease basically - it's pretty cushy insurance). Once we have the baby we won't be having one for at least a year - which gives the opportunity to switch onto an open market plan and save a good chunk of money every month.

Keep the answers coming. Thanks!
posted by jimmy0x52 at 3:14 PM on July 23, 2007

Where is the baby going to be covered? On your insurance or on your wife's? I'm sorry if I seem confused.
posted by MeetMegan at 3:33 PM on July 23, 2007

Nthing that this doesn't seem to make sense. Especially if you are going to add the baby to your coverage -- lots of plans are either "single" or "family" and for family it doesn't matter how many people are on the plan.

Also, keep in mind that if you are considering adding your wife back on in a year, you need another qualifying event - and while birth is one, getting pregnant isn't.

To answer your actual question, you should have made the move at the time of the qualifying event -- that is, when she quit her job. In some cases, you can change coverage retroactively, but not this far away, and not when you've actually been using the insurance. It is worth confirming, though, that the birth doesn't mean you can take her off - the way this was explained to me, when a qualifying event happens, you can make any changes you want to your coverage. YMMV based on your employer's actual plan (and the fact that my benefits person might actually be wrong - she's sort of a ding dong sometimes).
posted by dpx.mfx at 4:36 PM on July 23, 2007

Please, please, please be sure you know all the implications of doing this before you act. If you look for all the individual health insurance questions here, you'll notice that the insurance companies can (and do) turn people down for very, very minor things (my doctor told me one young woman with no health history was turned down because she had a short bout with anemia for which she was taking iron pills). Plus, many individual policies will charge extra for maternity insurance (I'm not sure if I've totally understood your question). But be very very careful before taking her off your insurance. Even if she's extremely healthy, she will have to disclose any doctor she's seen for at least the last five years (sometimes 10), for anything, and as I said above, they will choose any reason not to insure her.
posted by la petite marie at 4:49 PM on July 23, 2007

Sorry - me again. I hit "post" before I meant to. I used to work for an insurance company, and they can use things that might have been due to her pregnancy (such as high blood pressure) to deny her, even if it never happened before and probably won't happen again.

In the future, she will also always be asked if she's ever been turned down. Also, once someone has been turned down for a policy, all the info goes to a national clearing house for any other insurance company to access for health or life insurance.

Just be sure to read all the fine print in each policy and compare them. Although your group policy may be expensive, I'm guessing it may have better coverage for things like maximum out-of-pocket expenses, lifetime max, percentage co-pay, number of providers, etc.
posted by la petite marie at 4:54 PM on July 23, 2007

Unfortunately, it's not just expensive, it's unaffordable with two dependants.
posted by jimmy0x52 at 6:49 AM on July 25, 2007