There are many regulatory factors that influence how a plan sets its eligibility requirements. Plans have much freedom in determining which individuals are eligible for coverage, but they must also factor in laws that impact eligibility.
When a plan must comply with healthcare reform, eligibility and enrollment requirements are impacted in several ways:
1. Employer Mandate. The employer mandate generally defines full time employees as those who work 30 or more hours per week or 130 hours per month. If a plan is subject to the employer mandate, then they will want to ensure that, at a minimum, they are covering those employees meeting the hourly requirement or the plan may face penalties. In addition, plans subject to the employer mandate must cover any dependent children through the end of the month in which they turn 26 or face a penalty. If a plan is not subject to healthcare reform, then they have flexibility in how they define full time employees and any other eligibility requirements they might adopt. For more information on these penalties, please visit our dedicated Employer Mandate page.
2. Waiting Periods. Plans may not apply a waiting period that is longer than 90 days before an individual may enroll in coverage.
3. Pre-existing condition exclusions. Plans may no longer prohibit an individual from enrolling in a plan due to a pre-existing condition.
4. Rescissions of Coverage. It is very important for plans to have clearly defined eligibility requirements since the prohibition against rescissions has reduced a plan's ability to retroactively terminate coverage.
5. Special Enrollment Rights. Plans that are subject to HIPPA's special enrollment requirements are required to allow enrollment opportunities outside of the open enrollment period if an individual experiences a special enrollment event.
6. Dependent Child Eligibility. For plans that are subject to healthcare reform, coverage of dependent children must be offered until the dependent reaches age 26.
For more information:
- Qualified Medical Child Support Orders
- Domestic Partner Eligibility
- Special Enrollment Rights
- Dependent Child Eligibility
- Spousal Eligibility
This content is being provided as an informational tool. It is believed to be accurate at the time of posting and is subject to change. It is recommended that plans consult with their own experts or counsel to review all applicable federal and state legal requirements that may apply to their group health plan. By providing this information, Meritain Health is not exercising discretionary authority or assuming a plan fiduciary role, nor is Meritain Health providing legal advice.