Skip to main content

Qualifying Events

  • Qualifying events.
  • Reminders.
  • Leave without pay.
  • USERRA.
  • Midyear change checklist.

Qualifying events

Certain life changes, known as qualifying events or midyear changes, allow employees to add or drop benefits as well as dependents. These events can happen any time during the year and more than one event can happen at a time. To make a change, an Insurance Enrollment Form or Insurance Change Form must be completed within 30 days of the qualifying event. Requests for changes received after the deadline are denied.

Qualifying events include:

  • A change in marital status, such as marriage, divorce or the death of a spouse.
  • A change in the number of dependents, such as the birth of a child.
  • A change in employment status that affects an employee’s eligibility.
  • A change in the coverage of a spouse or dependent under another employer’s plan.
  • A change in a dependent’s status that causes them to gain or lose eligibility.
  • The gain or loss of other health coverage that is not an excepted benefit or other group, dental, vision or life coverage. Refer to Excepted Benefits in the Glossary section.
  • The commencement or termination of adoption procedures.
  • Court judgments, decrees or orders.
  • Medicare or Medicaid eligibility for an employee or dependent.
  • An employee’s eligibility for leave under the Family and Medical Leave Act.
  • When an employee no longer lives or works within their HMO ZIP code service area (only a change of health plans is allowed).

NOTE: Changes in coverage due to Medicaid eligibility are limited to two changes per plan year; once out and once back in or vice versa.

When an employee becomes Medicare eligible, they have two options:

  • Continue coverage through the employer group health plan and defer Part B enrollment. The employer’s plan will remain the primary payer.   This option allows the employee to avoid a Medicare late enrollment penalty. 
  • Discontinue coverage through the employer group health plan. Medicare becomes the primary payer for Medicare-covered services. An employer cannot provide a Medicare supplement or MAPD plan, or pay a subsidy for such coverage.

Midyear elections are allowed under the circumstances outlined in Title 26, Section 125 of the Internal Revenue Code. An employee must notify and provide documentation to you within 30 days of a qualifying event. You are required to keep documentation to support a qualifying event and provide that documentation to EGID upon request.

Employees who do not elect to have their benefit costs withheld through a pre-tax payroll deduction and/or employers who do not administer their employees’ benefits under a Section 125 plan must still follow the rules for midyear changes under Section 125 guidelines.

Reminders

Employee coverage can be added or dropped only within 30 days of an employee’s eligibility date, during the annual Option Period or with a Section 125 qualifying event. These same rules apply to dependent coverage. Most changes are effective the first day of the month following notification. Financial hardship is not a valid qualifying event that allows an employee to drop coverage.

If an employee did not elect coverage at initial enrollment, coverage can be added only during the annual Option Period or with a qualifying event. If coverage is declined due to enrollment in another group plan, the member and dependents may enroll in coverage through EGID within 30 days of losing other coverage. 

If an employee’s provider leaves their plan, it is not a qualifying event that allows the employee to change plans midyear. The employee must choose another provider within their plan’s network, or pay non-network charges. 

Oklahoma law prohibits dropping a spouse or dependent child from coverage while in the process of a divorce or legal separation. It is important the employee contact their legal counsel for advice before making any changes to their coverage.

Leave without pay

If an employee is on leave without pay, their insurance coverage can continue for up to 24 months. The employee is responsible for payment of all premiums to the employer during this time. At the end of the 24-month period, you can terminate all coverage; however, if workers’ compensation or disability insurance is involved, contact your legal counsel.

Going on and returning from leave without pay are both qualifying events that allow an employee to make certain changes to coverage.

USERRA

Under the Uniformed Services Employment and Reemployment Rights Act of 1994, coverage can be continued for up to 24 months. USERRA provides certain rights and protections for all employees called to serve our nation. All branches of the military, including the Army, Navy, Marines, Air Force, Coast Guard and all military reserve and National Guard units, come under USERRA.

In addition to health care coverage provided by the military, employees can:

  • Retain all coverage. You are responsible for collecting and forwarding all premiums to EGID.
  • Discontinue member coverage but retain dependent coverage. This is the COBRA option and dependents are billed directly at 102% of premiums, the COBRA rate, for health, dental and/or vision coverage. Under COBRA rules, life insurance cannot be retained.
  • Discontinue all coverage except life insurance. The member is billed directly.
  • Discontinue all member and dependent coverage.

If the employee elects to discontinue all coverage except life insurance, have them complete the USERRA Life Insurance Form. You must sign and return the completed form to EGID. 

There is no penalty when an employee renews coverage upon discharge from active duty if coverage is elected within 30 days of their return to the same employment.

NOTE: The HealthChoice Disability Plan is not available to state and participating county employees called to active military service. However, upon return to regular employment for five consecutive days, they become eligible for disability coverage.

Midyear change checklist

  • Make sure the employee has a recognized qualifying event and request documentation, e.g., proof of the event.
  • Obtain either an Insurance Enrollment Form or Insurance Change Form as appropriate and complete the Employer Information section.
  • Give the form to the employee to complete and provide the date the form must be returned to you.
  • Check that the employee has completed the form legibly and confirm elections with the employee.
  • Review the back of the form to make sure the employee has all required signatures and dates completed.
  • Prepare a COBRA packet for dropped dependents, if applicable.
  • Sign and date the form in the Insurance Coordinator Signature section. Your signature verifies that you know the form is correct and that you have the documentation to support it.
  • If you use Employer Self-Service, make the change to the employee’s information.
  • If you do not use Employer Self-Service, make a copy of the front and back of the form and mail the original to EGID, Attn: Member Accounts, P.O. Box 58010, Oklahoma City, OK 73157-8010; or fax to 405-717-8939 or 405-717-8942.
  • Keep a copy of the form and all documentation in the employee’s file. 

Common qualifying events

LIFE EVENT ADD DROP CHANGE PLAN COBRA NOTES
New hire, new eligibility or rehired after 30 days Yes No No No An employer probationary period may affect eligibility date
Acquire a dependent Yes No No No  
Loss of eligibility for a covered dependent No  Yes No Yes Employee and spouse divorce; a child turns 26
Loss of other group coverage (member or dependent) Yes No No No Affects only the type of coverage lost
Gain other group coverage (member or dependent) No Yes No No Affects only the type of coverage gained
Move out of HMO plan’s service area No No Yes No If employee works in HMO service area, then no QE
Commence FMLA leave or active military duty No Yes No Yes  
Return from FMLA leave or active military duty (< 2 years)   Yes No No No Renew within 30 days of return
Loss of employment and eligibility No Yes No Yes If termination is due to gross misconduct, employer may determine eligibility for COBRA
Rehire < 30 days with the same employer No No No No Enrollment limited to previous coverage
Death of the member No Yes  No Yes Refer to Surviving Dependents
Court-ordered coverage Yes Yes No  May apply to dependent Must follow instructions from the court
Enrollment in coverage through marketplace  No Yes No Yes Marketplace plan must be effective immediately following drop of coverage

4173

Group Label:

Back to Top