HIPAA Special Enrollment Rights

Group health plans often provide eligible employees with two regular opportunities to elect health coverage—an initial enrollment period when an employee first becomes eligible for coverage and an annual open enrollment period before the start of each plan year.

To make health coverage more portable, the Health Insurance Portability and Accountability Act (HIPAA) requires group health plans to provide special enrollment opportunities outside of the plans’ regular enrollment periods in certain situations.

Special enrollment must be provided in these situations:

• A loss of eligibility for other health coverage;
• Termination of eligibility for Medicaid or a state Children’s Health Insurance Program (CHIP);
• The acquisition of a new spouse or dependent by marriage, birth, adoption or placement for adoption; and
• Becoming eligible for a premium assistance subsidy under Medicaid or a state CHIP.

Affected Health Plans

• Both self-insured and fully insured plans must provide special enrollment rights.
• Certain categories of coverage are exempt from HIPAA’s special enrollment rules, such as limited-scope vision and dental benefits.
• Retiree-only plans and most health FSAs are also exempt from HIPAA’s special enrollment rules.

Special Enrollment Rights

• HIPAA allows eligible individuals to enroll in health plan coverage outside of the regular enrollment periods.
• These special enrollment rights apply to employees and their dependents, depending on the circumstance.
• Most employers allow employees to change their pre-tax benefit elections when they experience a special enrollment event.

Links & Resources

• The Department of Labor’s (DOL) compliance assistance guide for health benefits, which covers HIPAA special enrollment rights.
• Federal regulations regarding HIPAA special enrollment rights.
• FAQs regarding special enrollment rights after losing eligibility for individual coverage.