Rules for Benefit Changes
Other than during annual open enrollment, you may only make changes to your benefit elections if you experience a qualified status change or qualify for a "special enrollment". If you qualify for a mid‐year benefit change, you may be required to submit proof of the change or evidence of prior coverage.
Qualified Status Changes include:
- Change in legal marital status, including marriage, divorce, legal separation, annulment, and death of a spouse.
- Change in number of dependents, including birth, adoption, placement for adoption, or death of a dependent child.
- Change in employment status that affects benefit eligibility, including the start or termination of employment by you, your spouse, or your dependent child.
- Change in work schedule, including an increase or decrease in hours of employment by you, your spouse, or your dependent child, including a switch between part‐time and full‐time employment that affects eligibility for benefits.
- Change in a child's dependent status, either newly satisfying the requirements for dependent child status or ceasing to satisfy them.
- Change in place of residence or worksite, including a change that affects the accessibility of network providers.
- Change in your health coverage or your spouse's coverage attributable to your spouse's employment.
- Change in an individual's eligibility for Medicare or Medicaid.
- A court order resulting from a divorce, legal separation, annulment, or change in legal custody (including a Qualified Medical Child Support Order) requiring coverage for your child.
- An event that is a "special enrollment" under the Health Insurance Portability and Accountability Act (HIPAA) including acquisition of a new dependent by marriage, birth or adoption, or loss of coverage under another health insurance plan.
- An event that is allowed under the Children's Health Insurance Program (CHIP) Reauthorization Act. Under provisions of the Act, employees have 60 days after the following events to request enrollment if:
Employee or dependent loses eligibility for Medicaid (known as Medi‐Cal in CA) or CHIP (known as
Healthy Families in CA).
- Employee or dependent becomes eligible to participate in a premium assistance program under
Medicaid or CHIP.
Two rules apply to making changes to your benefits during the year:
- Any change you make must be consistent with the change in status, AND
- You must make the change within 30 days of the date the event occurs (unless otherwise noted above).