Special Enrollment Periods (SEPs) and Qualifying Events (QEs)

How life events impact health care enrollment

When life changes occur — whether planned or unexpected — your employees may need to update their health insurance coverage. These updates can occur outside of the annual open enrollment period, thanks to Special Enrollment Periods (SEPs) and Qualifying Events (QEs). As an employer, it's important to understand how these events can impact both your employees and your company’s benefits management.

There are a few ways employees can access or adjust their health benefits coverage:

1. Initial Enrollment Opportunity
   This refers to the first time an employee or their dependents become eligible for health insurance, such as when they first begin employment with your company. At this time, they can enroll in your employer-sponsored health plan, and the enrollment typically happens once during this initial period.
2. Special Enrollment Periods (SEPs) After Qualifying Events
   When a QE occurs, your employees may qualify for an SEP. This allows them to adjust their coverage or enroll in a new plan outside the usual open enrollment window. Key QEs, such as marriage, divorce, birth, or job loss, could make your employees eligible for changes in their health coverage.

For example, a divorce might lead to an employee needing to change their health plan if they were previously covered under a spouse’s employer-sponsored insurance. They can use the SEP to select a new plan, ensuring they are not left without coverage.

What are Qualifying Events (QEs)?
A Qualifying Event is a major life change or event that allows employees to enroll in or make changes to their health insurance outside of the usual open enrollment window. These events typically trigger a Special Enrollment Period (SEP), during which your employees can make the necessary adjustments to their health coverage.

Common Qualifying Events include:

• Marriage or divorce. Employees may add or remove a spouse from their health plan following a marriage or divorce.
• Having, adopting or fostering a child. The birth, adoption or fostering of a child qualifies employees to add the new child to their health plan. When adding a newborn as a qualifying event, other dependents can also be added to the existing coverage.
• Job loss or change in employment. If an employee loses their job, or changes job status (e.g., from full-time to part-time), they may be eligible for SEP to enroll in or adjust their health insurance plan.
• Change in residence. Moving to a different ZIP code or county that affects health insurance options can trigger an SEP.
• Turning 26 or 65. An employee’s child turning 26 may no longer be covered under their parent's plan, and turning 65 qualifies for Medicare enrollment.
• Eligibility for government programs. Employees who gain or lose eligibility for Medicaid or CHIP (Children's Health Insurance Program) may qualify for SEP.

Each QE typically comes with a limited window — usually 30 to 60 days — for your employee to make changes to their coverage. It's essential that your company provides clear communication on these windows and the process for making adjustments.

What employers should do

• Timely communication. Employees need to be informed of their rights to enroll or make changes following a QE. Provide clear instructions and deadlines for enrollment after a QE occurs.
• Documentation requirements. Employees may need to provide documentation of the QE (such as proof of marriage, divorce or job loss). Be sure your HR department is ready to process these changes efficiently.
• COBRA options. If an employee loses coverage due to job loss, they may be eligible for COBRA, which allows them to temporarily keep their employer-sponsored health insurance by paying the full premium. You should inform employees about their rights to COBRA benefits and help guide them through the process.
• Employee benefits guidance. Offer resources or consultations to help employees understand their health insurance options, including Marketplace (Healthcare.gov) plans if they are no longer eligible for employer-sponsored coverage.

How to support employees through changes
When a QE occurs, it’s important to guide employees on their options for new coverage.

For companies with fewer than 50 employees, if the decision is made to stop offering group coverage, employees will have a limited window to secure new coverage. Typically, they’ll have 60 days to enroll in a new plan or other options, such as COBRA, if applicable. It’s crucial to act within this time frame to avoid any gaps in coverage.

Employees should take the following steps:

1. Check if they qualify for financial assistance. Some employees may qualify for subsidies on marketplace plans based on income. Let them know they can access calculators on Healthcare.gov to determine potential savings.
2. Review health plan options. If switching to the Marketplace, employees should review the plan options available to them, including understanding network differences. For example, if employees are transitioning from an employer-sponsored PPO (Preferred Provider Organization) plan to a Marketplace plan, they may encounter differences in provider networks. Marketplace plans may offer more limited options, such as EPO (Exclusive Provider Organization) plans, which typically don’t cover out-of-network care except in emergencies. Encourage employees to verify whether their preferred doctors and hospitals are in-network under the new plan to avoid unexpected costs.
3. Enroll. Once employees have reviewed their options, they can enroll in a new plan through your company’s offerings or via the Marketplace if necessary.

Key takeaways for employers:

• Understand that life events like marriage, divorce, birth, and job loss can trigger Special Enrollment Periods.
• Be proactive in communicating with employees about their health benefits, especially after qualifying events.
• Provide clear guidance about documentation, deadlines and the steps employees need to take to enroll in or change their coverage.
• Keep employees informed of their COBRA and Medicaid options in case they lose employer-sponsored coverage.
• Reach out to your representative to help transition Medicare eligible employees to a Medicare plan.

With the right resources and clear communication, you can help your employees make informed decisions and ensure they have the coverage they need during these transitional times.

We’re here to help
Helping your employees navigate their health insurance options can be challenging, but offering clear, accessible guidance can make a big difference. If you need support with enrollment, forms, benefit or renewal information or eligibility questions, reach out to your sales representative or refer to the Group Administrator Manual. 

You can also find information about all our health plan options at bcbsks.com.