Wash. Admin. Code § 284-43-1020 - Special enrollment requirements for small group plans

Current through Register Vol. 21-24, December 15, 2021

(1) A "special enrollment period" means a period of time outside the initial or annual group renewal period during which an individual applicant may enroll if the individual has experienced a qualifying event. An issuer must make periods for special enrollment in its small group plans available to an otherwise eligible applicant if the applicant has experienced one of the qualifying events identified in this section.
(2) A qualifying event for special enrollment in small group plans offered on or off the health benefit exchange is one of the following:
(a) The loss of minimum essential benefits, including loss of employer sponsored insurance coverage, or of the coverage of a person under whose policy they were enrolled, unless the loss is based on the individual's voluntary termination of employer sponsored coverage, the misrepresentation of a material fact affecting coverage or for fraud related to the terminated health coverage;
(b) The loss of eligibility for medicaid or a public program providing health benefits;
(c) The loss of coverage as the result of dissolution of marriage or termination of a domestic partnership;
(d) A permanent change in residence, work, or living situation, whether or not within the choice of the individual, where the health plan under which they were covered does not provide coverage in that person's new service area;
(e) The birth, placement for adoption or adoption of the applicant for whom coverage is sought;
(f) A situation in which a plan no longer offers benefits to the class of similarly situated individuals that includes the applicant;
(g)Loss of individual or group coverage purchased on the health benefit exchange due to an error on the part of the exchange, the issuer or the U.S. Department of Health and Human Services;
(h) Marriage or entering into a domestic partnership, including eligibility as a dependent of an individual marrying or entering into a domestic partnership.
(3) Nothing in this rule is intended to alter or affect the requirements of RCW 48.43.517.
(4) An issuer may require reasonable proof or documentation that an individual seeking special enrollment has experienced a qualifying event.
(5) An issuer must offer a special enrollee each benefit package available to members of the group who enrolled when first eligible. A special enrollee cannot be required to pay more for coverage than other members of the group who enrolled in the same coverage when first eligible. Any difference in benefits or cost-sharing requirements constitutes a different benefit package.
(6) An issuer must include detailed information about special enrollment options and rights in its health plan documents provided pursuant to WAC 284-43-5130, and in any policy or certificate of coverage provided to an employer, plan sponsor, or enrollee. The notice must be substantially similar to the model notice provided by the U.S. Department of Labor or the U.S. Department of Health and Human Services.
(7) For children who experience a qualifying event, if the selected plan is not the plan on which the parent is then enrolled, or if the parent does not have coverage, the issuer must permit the parent to enroll when the child seeks enrollment for dependent coverage. An enrolling child must have access to any benefit package offered to employees, even if that requires the issuer to permit the parent to switch benefit packages.


Wash. Admin. Code § 284-43-1020
WSR 16-01-081, recodified as § 284-43-1020, filed 12/14/15, effective 12/14/15. Amended by WSR 16-14-106, Filed 7/6/2016, effective 8/6/2016

Statutory Authority: RCW 48.02.060, 48.18.120(2), 48.20.450, 48.43.0211, 48.43.720(3), 48.44.050, 48.46.200, 45 C.F.R. §§ 147.104, 147.106, 155.420, and 155.725. WSR 14-01-042 (Matter No. R 2013-02), § 284-170-410, filed 12/11/13, effective 1/1/14.

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