Mid-Year Election Changes – When Can Employees Add Coverage?

Any time an employee requests to add coverage for themselves or a family member mid-plan year (outside open enrollment), we first look to HIPAA special enrollment rules. If a HIPAA special enrollment event is triggered, a group health plan is generally required to allow mid-year enrollment so long as enrollment is timely requested.

HIPAA special enrollment rights are only triggered for the following events: (i) Loss of coverage (loss of eligibility, not voluntary termination or termination due to nonpayment); (ii) Acquisition of a new dependent through marriage, birth or adoption; or (iii) Becoming newly eligible for a Medicaid or CHIP subsidy.

HIPAA special enrollment rights apply to group health plans, but not to excepted benefits or non-medical benefits. While most plans other than major medical are not required to allow mid-year enrollment, some plans (e.g., dental or vision plans) may be written with special enrollment rights similar to those under HIPAA.

It is important to distinguish between HIPAA special enrollment events and §125 permitted election change events, as these are often grouped together as “qualifying life events” but serve different purposes. HIPAA special enrollment events are more limited in scope and represent the only situations in which a group health plan is legally required to allow mid-year enrollment. In contrast, §125 events are broader and allow employees to change their existing pre-tax elections mid-year. A HIPAA special enrollment event also qualifies as a §125 event.

Download this flow chart to use as a reference for determining what changes may be permissible when a participant requests a mid-year change in benefit elections