2005 Active Employee Health Insurance Handbook - Qualifying Events

The Commonwealth of Kentucky's Public Employee Health Insurance Program is provided through a Section 125 plan. This allows you to pay for your health insurance premiums with pre-tax monies, which saves you money. Section 125 plans are federally regulated. Federal guidelines state that if your health insurance is offered through a Section 125 plan, you cannot make a change in your health insurance option outside of the Open Enrollment period unless you experience an appropriate Qualifying Event. Qualifying Events are also governed by federal guidelines and the Department for Employee Insurance cannot modify the Qualifying Events it has adopted for use in this Program.

If you experience a Qualifying Event during the Plan Year, you are allowed to make changes to your health insurance coverage. Those allowed changes must be consistent with and on account of the Qualifying Event you experience.

Some Qualifying Events (such as marriage, birth, adoption, loss of group coverage, etc.) allow you to add dependents to your current coverage. Coverage for dependents being added to a plan will be effective on the first day of the first month after the employee's signature on the application or Add Form. Keep in mind that the Program is a pre-paid health insurance program. If you experience a Qualifying Event that allows you to add dependents, you may be in arrears for payment of premiums. If this happens, you will be responsible for any premiums due.

Exceptions:

Birth - children added due to this Qualifying Event are effective on the date of birth, if application is completed within the specified timeframe.

Adoption/Placement for adoption - children added due to this Qualifying Event are effective on the date of adoption or placement for adoption, if application is completed within the specified timeframe.

Some Qualifying Events (such as divorce, dependent ineligibility, death, gaining other group coverage, Medicare eligibility, etc.) allow you to drop dependents from your current coverage. Health coverage for dependents dropped from a plan ends on the last day of the month in which the employee signs the Drop Form.

Exceptions:

Loss of eligibility or dependent status such as divorce, a child's marriage, a child's establishment of a separate primary residence and age limitations - dependents dropped due to these Qualifying Events are terminated effective on the last day of the month in which the event occurs.

The Qualifying Event "Moving Out of the Service Area" may allow an employee to make a change to his/her existing carrier. This occurs when an employee moves out of his/her selected county of coverage (home or work, or contiguous, if applicable) into another county where the employee's existing carrier is not available.

Example:

Employee has coverage in her home county and she moves her residence to a different county in which her carrier is not available. In this case, the employee will be allowed to:

• If an employee has coverage in her work county and she moves her residence (home county) to a different county in which her carrier is not available, the employee will not be allowed to make a change in carrier because her coverage is still available in her county of choice (work).
• Changes in options during the Plan Year are not allowed.

Employees have no later than thirty (30) days after the event occurs to sign the appropriate form requesting a change.

Exceptions:

Adding a newborn only - employee has 60 days*

Adoption/Placement for adoption - employee has 60 days*

*If the employee is requesting to add additional dependents (other than the newborn or the newly adopted/placed child), he/she will have 30 days (not 60) after the event to make the request and sign the application or Add Form.

The effective dates for Qualifying Events are based on the date the event occurred.

Exceptions:

• Notification Date: This is the date the employee is notified by another source that an event affecting his/her eligibility for a different coverage has occurred. The Department for Employee Insurance will accept a notification date (in lieu of the event date) only in the following cases:

Applications for changes due to a Qualifying Event cannot be signed before the event occurs.

Exceptions:

• Pre-Signing: This is the ability of an employee to sign a form prior to a Qualifying Event taking place. The Department for Employee Insurance will accept a pre-signed form only in the following cases:

*The effective dates of the indicated Qualifying Events are determined following the same guidelines as indicated under on [ "Effective Dates" ] of this section. Therefore, pre-signing an application or form may result in double coverage or a gap in coverage.

Spouse/Retiree Has Different Open Enrollment Period:

The following processing rules apply to this Qualifying Event:

• The Qualifying Event date is the last day of the spouse/retiree's open enrollment period.
• The application or form can be signed prior to the event date.
• The effective date of the selected coverage will be manually entered to correspond with the effective date of the spouse/retiree's open enrollment elections.

Moving Out of the Service Area: The effective date of this Qualifying Event is the first day of the month following the employee's signature date. Calculation of effective dates with the newly selected coverage will be done prospectively.

You should use the health insurance application for the following events:

• Initial enrollment at hire date (New Employee)
• Open Enrollment
• If you are employed by a group that joins the Public Employee Health Insurance Program for the first time (New Group)
• If you, or your dependents, elect to continue coverage through COBRA;
• If you move out of the service area
• Other or Previously Waived - if you previously waived or marked "other", you must enter the Qualifying Event date and a description of the Qualifying Event.

You should use the Add Form if:

You are currently enrolled and you experience a Qualifying Event that allows you to add any dependents to your plan.

You should use the Drop Form if:

You are currently enrolled and you experience a Qualifying Event that allows you to drop any dependents from your plan.

Divorce/Legal Separation

If dropping spouse from plan:

• Filed decree signed by a judge and date-stamped "filed."

If enrolling because event caused loss of other coverage:

• Proof that you were covered under your spouse's plan and no longer eligible (HIPAA certificate or letter from employer). Letter should identify date of insurance termination and persons who were covered by policy.

Note: The Department for Employee Insurance reserves the right to request a copy of the filed divorce decree as deemed necessary.

Adoption or Placement for Adoption

• Papers from the Cabinet for Health and Family Services;
• Signed and date-stamped "filed" papers from the court;
• Letter from the adoption agency on letterhead;
• Legal document from a U.S. Court; or
• Official document translated into English.

Judgment decree or Administrative Order relating to health coverage for your child

• A filed or dated court decree;
• Agency Administrative Order; or
• National Medical Support Notice.

Employee, spouse or dependent enrolled in Employer's health plan becomes entitled to Medicare or Medicaid

• Initial eligibility letter from the Medicare/Medicaid Office

Note: The Department for Employee Insurance reserves the right to request a copy of the Medicare/Medicaid card as deemed necessary.

Loss of other group health insurance coverage that entitles employee or family member to be enrolled in accordance with HIPAA

• HIPAA certificate from prior carrier;
• Letter from employer/previous employer (letter should identify date of insurance termination and persons who were covered by policy); or
• Termination letter from government agency under which previous coverage was held.

Adding a grandchild

• Guardianship papers.

Biological children

• Can be added to your coverage by selecting the Qualifying Event of Birth (newborn only) or Birth plus other dependents on the Add Form.
• The effective date of coverage for children added due to this Qualifying Event is the child's date of birth (DOB).
• The deadline to add a newborn only is sixty (60) days from the DOB; the deadline to add a newborn plus other dependents is thirty (30) days from the date of birth.
• No supporting documentation is required.

Adopted children or children placed for adoption

• Can be added to your coverage by selecting the Qualifying Event of Adoption/Placement for adoption (adopted child only) or Adoption/placement for adoption plus other dependents on the Add Form.
• The effective date of coverage is the adoption date or the date the children is placed for adoption.
• The deadline to add an adopted child or a child placed for adoption only is sixty (60) days from the adoption or placement date. The deadline to add an adopted child or a child placed for adoption plus other dependents is thirty (30) days from the adoption or placement date.
• The supporting documentation required is listed under [ "Supporting Documentation".]

Children other than biological or adopted children (Grandchildren, stepchildren, foster children and other children) [ (refer to Enrollment and Eligibility Section for the definition of dependents).]

• Can be added to your coverage by selecting the Qualifying Event of Full Legal Guardianship, Administrative Order or Court Order on the Add Form.
• The effective date of coverage is the first day of the first month after the employee's signature on the Add Form.
• The deadline to add children under this Qualifying Event is no later than thirty (30) days from the Qualifying Event. The Qualifying Event date is the date that the Legal Guardianship, Court Order or Administrative Order is obtained.
• The Add Form cannot be signed before the Qualifying Event occurs.
• The supporting documentation required:

All children added to an employee's health insurance coverage must meet the dependent eligibility requirements as described in the [ Eligible Dependents Section].

The above described Qualifying Events are not the only events that allow you to add your eligible dependent children to your health insurance coverage. Other events such as marriage and loss of other group coverage also allow you to add eligible dependents to your plan.

• The appropriate form must be completed and signed within the specified deadlines. Applications/forms signed after the appropriate deadlines will not be accepted.
• Supporting documentation must be submitted when required. The inability to obtain the required supporting documentation is not a reason for an extension.
• A list of the permitted Qualifying Events and necessary forms are included in the Department for Employee Insurance Web site at [http://personnel.ky.gov/dei.htm]. You may also contact your agency's health insurance coordinator or the Department for Employee Insurance's Member Services Branch for additional information regarding Qualifying Events.