Qualifying Events

List of Qualifying Events
Change Checklist
Leave Without Pay (LWOP)
USERRA (Uniformed Services Employment and Re-employment Rights Act)
List of Qualifying Events

Certain life changes known as qualifying events (QE) allow employees to change benefits. Also known as midyear qualifying events, 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 can be 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 the employee’s eligibility
• A change in the coverage of a spouse or dependent under another employer's plan
• A change in dependent status that causes them to meet, or fail to meet eligibility requirements
• Gaining or losing other group coverage
• Commencing or terminating adoption procedures
• Court judgments, decrees, or orders
• Medicare eligibility for an employee or dependent
• Medicaid eligibility for an employee or dependent, limited to two changes per plan year; once out and once back or vice versa
• An employee’s eligibility for leave under the Family Medical Leave Act (FMLA)
• An employee no longer lives or works within their HMO ZIP Code service area (only a change of health plans is allowed)

Note: If an employee’s provider leaves their plan, it is not a qualifying event for the employee to change plans midyear. The employee must choose another provider within their plan’s network, or pay non-network charges if this option is available.

Common Qualifying Events

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 their employer within 30 days of a qualifying event. The employer is responsible for keeping documentation to support a qualifying event and providing documentation to OSEEGIB 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.  (See OSEEGIB Rules 360:10-3-27.1)

Change Checklist 

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.  (See OSEEGIB Rules 360:10-3-27.1)  Financial hardship is not considered a qualifying event.

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

Making a Midyear Change

Make sure the employee has a recognized qualifying event.  (See Qualifying events include and the table of Common Qualifying Events)
Obtain the Insurance Change Form.
Fill out the “Employer Information”.
Give the form to the employee to complete and inform them of the deadline for returning the form to you.
Check that the employee has completed the form and confirm selections with employee.
Obtain documentation of the qualifying event.  (See List of Qualifying Events)
Obtain proof of other group health insurance if the employee is electing dental and life insurance with OSEEGIB health.  (See HIPAA)
Review form back to make sure the employee has all required signatures and dates completed.
Prepare a COBRA packet for dropped dependents, if applicable.  (See COBRA)
Sign and date the form on the “Insurance Coordinator Signature” section.
If you use Web Enrollment, make the change to the employee’s information.  (See Web Enrollment)
If you do not use Web Enrollment, make a copy of the front and back of the form and mail the original form to OSEEGIB or fax to OSEEGIB at 1-405-717-8939 or 1-405-717-8942, “Attention: Accounting”.
Keep a copy of the form and any qualifying event documentation in the employee’s file.

Oklahoma law prohibits a member from dropping a spouse/dependents in anticipation of a divorce or legal separation. If your employee is in the process of a separation or divorce, it is important that they contact their legal counsel for advice before making any changes to their coverage.

Leave Without Pay (LWOP) 

If you have an employee who is on leave without pay, be aware that their insurance coverage can be continued for up to 24 months. The employee is responsible for payment of all premiums to the employer while on leave without pay. At the end of the 24-month period, you may 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 employees to make certain changes, depending on the situation.

USERRA 

Under the Uniformed Services Employment and Re-employment Rights Act of 1994 (USERRA), 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, all Military Reserve units, and all National Guard units come under USERRA.

In addition to health care provided by the military, employees have choices regarding their current coverage. Employees can:

• Retain all coverage. You are responsible for collecting and forwarding all premiums to OSEEGIB.
• 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.

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

Regardless of whether the member receives written or verbal military orders, OSEEGIB staff will assist you in making any benefit arrangements for the member.

If a member is a member of a Military Reserve unit or the National Guard and anticipates being called to active service, they need to notify you.