(a) Special enrollment for certain individuals who lose coverage--
(1) In general. A group health plan, and a health insurance issuer
offering health insurance coverage in connection with a group health
plan, is required to permit current employees and dependents (as defined
in Sec. 2590.701-2) who are described in paragraph (a)(2) of this
section to enroll for coverage under the terms of the plan if the
conditions in paragraph (a)(3) of this section are satisfied. The
special enrollment rights under this paragraph (a) apply without regard
to the dates on which an individual would otherwise be able to enroll
under the plan.
(2) Individuals eligible for special enrollment--(i) When employee
loses coverage. A current employee and any dependents (including the
employee's spouse) each are eligible for special enrollment in any
benefit package under the plan (subject to plan eligibility rules
conditioning dependent enrollment on enrollment of the employee) if--
(A) The employee and the dependents are otherwise eligible to enroll
in the benefit package;
(B) When coverage under the plan was previously offered, the
employee had coverage under any group health plan or health insurance
coverage; and
(C) The employee satisfies the conditions of paragraph (a)(3)(i),
(ii), or (iii) of this section and, if applicable, paragraph (a)(3)(iv)
of this section.
(ii) When dependent loses coverage--(A) A dependent of a current
employee (including the employee's spouse) and the employee each are
eligible for special enrollment in any benefit package under the plan
(subject to plan eligibility rules conditioning dependent enrollment on
enrollment of the employee) if--
(1) The dependent and the employee are otherwise eligible to enroll
in the benefit package;
(2) When coverage under the plan was previously offered, the
dependent had coverage under any group health plan or health insurance
coverage; and
(3) The dependent satisfies the conditions of paragraph (a)(3)(i),
(ii), or (iii) of this section and, if applicable, paragraph (a)(3)(iv)
of this section.
(B) However, the plan or issuer is not required to enroll any other
dependent unless that dependent satisfies the criteria of this paragraph
(a)(2)(ii), or the employee satisfies the criteria of paragraph
(a)(2)(i) of this section.
(iii) Examples. The rules of this paragraph (a)(2) are illustrated
by the following examples:
Example 1. (i) Facts. Individual A works for Employer X. A, A's
spouse, and A's dependent children are eligible but not enrolled for
coverage under X's group health plan. A's spouse works for Employer Y
and at the time coverage was offered under X's plan, A was enrolled in
coverage under Y's plan. Then, A loses eligibility for coverage under
Y's plan.
(ii) Conclusion. In this Example 1, because A satisfies the
conditions for special enrollment under paragraph (a)(2)(i) of this
section, A, A's spouse, and A's dependent children are eligible for
special enrollment under X's plan.
Example 2. (i) Facts. Individual A and A's spouse are eligible but
not enrolled for coverage under Group Health Plan P maintained
[[Page 657]]
by A's employer. When A was first presented with an opportunity to
enroll A and A's spouse, they did not have other coverage. Later, A and
A's spouse enroll in Group Health Plan Q maintained by the employer of
A's spouse. During a subsequent open enrollment period in P, A and A's
spouse did not enroll because of their coverage under Q. They then lose
eligibility for coverage under Q.
(ii) Conclusion. In this Example 2, because A and A's spouse were
covered under Q when they did not enroll in P during open enrollment,
they satisfy the conditions for special enrollment under paragraphs
(a)(2)(i) and (ii) of this section. Consequently, A and A's spouse are
eligible for special enrollment under P.
Example 3. (i) Facts. Individual B works for Employer X. B and B's
spouse are eligible but not enrolled for coverage under X's group health
plan. B's spouse works for Employer Y and at the time coverage was
offered under X's plan, B's spouse was enrolled in self-only coverage
under Y's group health plan. Then, B's spouse loses eligibility for
coverage under Y's plan.
(ii) Conclusion. In this Example 3, because B's spouse satisfies the
conditions for special enrollment under paragraph (a)(2)(ii) of this
section, both B and B's spouse are eligible for special enrollment under
X's plan.
Example 4. (i) Facts. Individual A works for Employer X. X maintains
a group health plan with two benefit packages--an HMO option and an
indemnity option. Self-only and family coverage are available under both
options. A enrolls for self-only coverage in the HMO option. A's spouse
works for Employer Y and was enrolled for self-only coverage under Y's
plan at the time coverage was offered under X's plan. Then, A's spouse
loses coverage under Y's plan. A requests special enrollment for A and
A's spouse under the plan's indemnity option.
(ii) Conclusion. In this Example 4, because A's spouse satisfies the
conditions for special enrollment under paragraph (a)(2)(ii) of this
section, both A and A's spouse can enroll in either benefit package
under X's plan. Therefore, if A requests enrollment in accordance with
the requirements of this section, the plan must allow A and A's spouse
to enroll in the indemnity option.
(3) Conditions for special enrollment--(i) Loss of eligibility for
coverage. In the case of an employee or dependent who has coverage that
is not COBRA continuation coverage, the conditions of this paragraph
(a)(3)(i) are satisfied at the time the coverage is terminated as a
result of loss of eligibility (regardless of whether the individual is
eligible for or elects COBRA continuation coverage). Loss of eligibility
under this paragraph (a)(3)(i) does not include a loss due to the
failure of the employee or dependent to pay premiums on a timely basis
or termination of coverage for cause (such as making a fraudulent claim
or an intentional misrepresentation of a material fact in connection
with the plan). Loss of eligibility for coverage under this paragraph
(a)(3)(i) includes (but is not limited to)--
(A) Loss of eligibility for coverage as a result of legal
separation, divorce, cessation of dependent status (such as attaining
the maximum age to be eligible as a dependent child under the plan),
death of an employee, termination of employment, reduction in the number
of hours of employment, and any loss of eligibility for coverage after a
period that is measured by reference to any of the foregoing;
(B) In the case of coverage offered through an HMO, or other
arrangement, in the individual market that does not provide benefits to
individuals who no longer reside, live, or work in a service area, loss
of coverage because an individual no longer resides, lives, or works in
the service area (whether or not within the choice of the individual);
(C) In the case of coverage offered through an HMO, or other
arrangement, in the group market that does not provide benefits to
individuals who no longer reside, live, or work in a service area, loss
of coverage because an individual no longer resides, lives, or works in
the service area (whether or not within the choice of the individual),
and no other benefit package is available to the individual;
(D) A situation in which an individual incurs a claim that would
meet or exceed a lifetime limit on all benefits; and
(E) A situation in which a plan no longer offers any benefits to the
class of similarly situated individuals (as described in Sec.
2590.702(d)) that includes the individual.
(ii) Termination of employer contributions. In the case of an
employee or dependent who has coverage that is not COBRA continuation
coverage, the conditions of this paragraph (a)(3)(ii) are satisfied at
the time employer contributions towards the employee's or
[[Page 658]]
dependent's coverage terminate. Employer contributions include
contributions by any current or former employer that was contributing to
coverage for the employee or dependent.
(iii) Exhaustion of COBRA continuation coverage. In the case of an
employee or dependent who has coverage that is COBRA continuation
coverage, the conditions of this paragraph (a)(3)(iii) are satisfied at
the time the COBRA continuation coverage is exhausted. For purposes of
this paragraph (a)(3)(iii), an individual who satisfies the conditions
for special enrollment of paragraph (a)(3)(i) of this section, does not
enroll, and instead elects and exhausts COBRA continuation coverage
satisfies the conditions of this paragraph (a)(3)(iii). (Exhaustion of
COBRA continuation coverage is defined in Sec. 2590.701-2.)
(iv) Written statement. A plan may require an employee declining
coverage (for the employee or any dependent of the employee) to state in
writing whether the coverage is being declined due to other health
coverage only if, at or before the time the employee declines coverage,
the employee is provided with notice of the requirement to provide the
statement (and the consequences of the employee's failure to provide the
statement). If a plan requires such a statement, and an employee does
not provide it, the plan is not required to provide special enrollment
to the employee or any dependent of the employee under this paragraph
(a)(3). A plan must treat an employee as having satisfied the plan
requirement permitted under this paragraph (a)(3)(iv) if the employee
provides a written statement that coverage was being declined because
the employee or dependent had other coverage; a plan cannot require
anything more for the employee to satisfy the plan's requirement to
provide a written statement. (For example, the plan cannot require that
the statement be notarized.)
(v) The rules of this paragraph (a)(3) are illustrated by the
following examples:
Example 1. (i) Facts. Individual D enrolls in a group health plan
maintained by Employer Y. At the time D enrolls, Y pays 70 percent of
the cost of employee coverage and D pays the rest. Y announces that
beginning January 1, Y will no longer make employer contributions
towards the coverage. Employees may maintain coverage, however, if they
pay the total cost of the coverage.
(ii) Conclusion. In this Example 1, employer contributions towards
D's coverage ceased on January 1 and the conditions of paragraph
(a)(3)(ii) of this section are satisfied on this date (regardless of
whether D elects to pay the total cost and continue coverage under Y's
plan).
Example 2. (i) Facts. A group health plan provides coverage through
two options--Option 1 and Option 2. Employees can enroll in either
option only within 30 days of hire or on January 1 of each year.
Employee A is eligible for both options and enrolls in Option 1.
Effective July 1 the plan terminates coverage under Option 1 and the
plan does not create an immediate open enrollment opportunity into
Option 2.
(ii) Conclusion. In this Example 2, A has experienced a loss of
eligibility for coverage that satisfies paragraph (a)(3)(i) of this
section, and has satisfied the other conditions for special enrollment
under paragraph (a)(2)(i) of this section. Therefore, if A satisfies the
other conditions of this paragraph (a), the plan must permit A to enroll
in Option 2 as a special enrollee. (A may also be eligible to enroll in
another group health plan, such as a plan maintained by the employer of
A's spouse, as a special enrollee.) The outcome would be the same if
Option 1 was terminated by an issuer and the plan made no other coverage
available to A.
Example 3. (i) Facts. Individual C is covered under a group health
plan maintained by Employer X. While covered under X's plan, C was
eligible for but did not enroll in a plan maintained by Employer Z, the
employer of C's spouse. C terminates employment with X and loses
eligibility for coverage under X's plan. C has a special enrollment
right to enroll in Z's plan, but C instead elects COBRA continuation
coverage under X's plan. C exhausts COBRA continuation coverage under
X's plan and requests special enrollment in Z's plan.
(ii) Conclusion. In this Example 3, C has satisfied the conditions
for special enrollment under paragraph (a)(3)(iii) of this section, and
has satisfied the other conditions for special enrollment under
paragraph (a)(2)(i) of this section. The special enrollment right that C
had into Z's plan immediately after the loss of eligibility for coverage
under X's plan was an offer of coverage under Z's plan. When C later
exhausts COBRA coverage under X's plan, C has a second special
enrollment right in Z's plan.
(4) Applying for special enrollment and effective date of coverage--
(i) A plan or issuer must allow an employee a period
[[Page 659]]
of at least 30 days after an event described in paragraph (a)(3) of this
section (other than an event described in paragraph (a)(3)(i)(D)) to
request enrollment (for the employee or the employee's dependent). In
the case of an event described in paragraph (a)(3)(i)(D) of this section
(relating to loss of eligibility for coverage due to the operation of a
lifetime limit on all benefits), a plan or issuer must allow an employee
a period of at least 30 days after a claim is denied due to the
operation of a lifetime limit on all benefits.
(ii) Coverage must begin no later than the first day of the first
calendar month beginning after the date the plan or issuer receives the
request for special enrollment.
(b) Special enrollment with respect to certain dependent
beneficiaries--(1) In general. A group health plan, and a health
insurance issuer offering health insurance coverage in connection with a
group health plan, that makes coverage available with respect to
dependents is required to permit individuals described in paragraph
(b)(2) of this section to be enrolled for coverage in a benefit package
under the terms of the plan. Paragraph (b)(3) of this section describes
the required special enrollment period and the date by which coverage
must begin. The special enrollment rights under this paragraph (b) apply
without regard to the dates on which an individual would otherwise be
able to enroll under the plan.
(2) Individuals eligible for special enrollment. An individual is
described in this paragraph (b)(2) if the individual is otherwise
eligible for coverage in a benefit package under the plan and if the
individual is described in paragraph (b)(2)(i), (ii), (iii), (iv), (v),
or (vi) of this section.
(i) Current employee only. A current employee is described in this
paragraph (b)(2)(i) if a person becomes a dependent of the individual
through marriage, birth, adoption, or placement for adoption.
(ii) Spouse of a participant only. An individual is described in
this paragraph (b)(2)(ii) if either --
(A) The individual becomes the spouse of a participant; or
(B) The individual is a spouse of a participant and a child becomes
a dependent of the participant through birth, adoption, or placement for
adoption.
(iii) Current employee and spouse. A current employee and an
individual who is or becomes a spouse of such an employee, are described
in this paragraph (b)(2)(iii) if either--
(A) The employee and the spouse become married; or
(B) The employee and spouse are married and a child becomes a
dependent of the employee through birth, adoption, or placement for
adoption.
(iv) Dependent of a participant only. An individual is described in
this paragraph (b)(2)(iv) if the individual is a dependent (as defined
in Sec. 2590.701-2) of a participant and the individual has become a
dependent of the participant through marriage, birth, adoption, or
placement for adoption.
(v) Current employee and a new dependent. A current employee and an
individual who is a dependent of the employee, are described in this
paragraph (b)(2)(v) if the individual becomes a dependent of the
employee through marriage, birth, adoption, or placement for adoption.
(vi) Current employee, spouse, and a new dependent. A current
employee, the employee's spouse, and the employee's dependent are
described in this paragraph (b)(2)(vi) if the dependent becomes a
dependent of the employee through marriage, birth, adoption, or
placement for adoption.
(3) Applying for special enrollment and effective date of coverage--
(i) Request. A plan or issuer must allow an individual a period of at
least 30 days after the date of the marriage, birth, adoption, or
placement for adoption (or, if dependent coverage is not generally made
available at the time of the marriage, birth, adoption, or placement for
adoption, a period of at least 30 days after the date the plan makes
dependent coverage generally available) to request enrollment (for the
individual or the individual's dependent).
(ii) Reasonable procedures for special enrollment. [Reserved]
(iii) Date coverage must begin--(A) Marriage. In the case of
marriage, coverage must begin no later than the first day of the first
calendar month beginning after the date the plan or
[[Page 660]]
issuer receives the request for special enrollment.
(B) Birth, adoption, or placement for adoption. Coverage must begin
in the case of a dependent's birth on the date of birth and in the case
of a dependent's adoption or placement for adoption no later than the
date of such adoption or placement for adoption (or, if dependent
coverage is not made generally available at the time of the birth,
adoption, or placement for adoption, the date the plan makes dependent
coverage available).
(4) Examples. The rules of this paragraph (b) are illustrated by the
following examples:
Example 1. (i) Facts. An employer maintains a group health plan that
offers all employees employee-only coverage, employee-plus-spouse
coverage, or family coverage. Under the terms of the plan, any employee
may elect to enroll when first hired (with coverage beginning on the
date of hire) or during an annual open enrollment period held each
December (with coverage beginning the following January 1). Employee A
is hired on September 3. A is married to B, and they have no children.
On March 15 in the following year a child C is born to A and B. Before
that date, A and B have not been enrolled in the plan.
(ii) Conclusion. In this Example 1, the conditions for special
enrollment of an employee with a spouse and new dependent under
paragraph (b)(2)(vi) of this section are satisfied. If A satisfies the
conditions of paragraph (b)(3) of this section for requesting enrollment
timely, the plan will satisfy this paragraph (b) if it allows A to
enroll either with employee-only coverage, with employee-plus-spouse
coverage (for A and B), or with family coverage (for A, B, and C). The
plan must allow whatever coverage is chosen to begin on March 15, the
date of C's birth.
Example 2. (i) Facts. Individual D works for Employer X. X maintains
a group health plan with two benefit packages--an HMO option and an
indemnity option. Self-only and family coverage are available under both
options. D enrolls for self-only coverage in the HMO option. Then, a
child, E, is placed for adoption with D. Within 30 days of the placement
of E for adoption, D requests enrollment for D and E under the plan's
indemnity option.
(ii) Conclusion. In this Example 2, D and E satisfy the conditions
for special enrollment under paragraphs (b)(2)(v) and (b)(3) of this
section. Therefore, the plan must allow D and E to enroll in the
indemnity coverage, effective as of the date of the placement for
adoption.
(c) Notice of special enrollment. At or before the time an employee
is initially offered the opportunity to enroll in a group health plan,
the plan must furnish the employee with a notice of special enrollment
that complies with the requirements of this paragraph (c).
(1) Description of special enrollment rights. The notice of special
enrollment must include a description of special enrollment rights. The
following model language may be used to satisfy this requirement:
If you are declining enrollment for yourself or your dependents
(including your spouse) because of other health insurance or group
health plan coverage, you may be able to enroll yourself and your
dependents in this plan if you or your dependents lose eligibility for
that other coverage (or if the employer stops contributing towards your
or your dependents' other coverage). However, you must request
enrollment within [insert ``30 days'' or any longer period that applies
under the plan] after your or your dependents' other coverage ends (or
after the employer stops contributing toward the other coverage).
In addition, if you have a new dependent as a result of marriage,
birth, adoption, or placement for adoption, you may be able to enroll
yourself and your dependents. However, you must request enrollment
within [insert ``30 days'' or any longer period that applies under the
plan] after the marriage, birth, adoption, or placement for adoption.
To request special enrollment or obtain more information, contact
[insert the name, title, telephone number, and any additional contact
information of the appropriate plan representative].
(2) Additional information that may be required. The notice of
special enrollment must also include, if applicable, the notice
described in paragraph (a)(3)(iv) of this section (the notice required
to be furnished to an individual declining coverage if the plan requires
the reason for declining coverage to be in writing).
(d) Treatment of special enrollees--(1) If an individual requests
enrollment while the individual is entitled to special enrollment under
either paragraph (a) or (b) of this section, the individual is a special
enrollee, even if the request for enrollment coincides with a late
enrollment opportunity under the plan. Therefore, the individual cannot
be treated as a late enrollee.
[[Page 661]]
(2) Special enrollees must be offered all the benefit packages
available to similarly situated individuals who enroll when first
eligible. For this purpose, any difference in benefits or cost-sharing
requirements for different individuals constitutes a different benefit
package. In addition, a special enrollee cannot be required to pay more
for coverage than a similarly situated individual who enrolls in the
same coverage when first eligible. The length of any preexisting
condition exclusion that may be applied to a special enrollee cannot
exceed the length of any preexisting condition exclusion that is applied
to similarly situated individuals who enroll when first eligible. For
rules prohibiting the application of a preexisting condition exclusion
to certain newborns, adopted children, and children placed for adoption,
see Sec. 2590.701-3(b).
(3) The rules of this section are illustrated by the following
example:
Example. (i) Facts. Employer Y maintains a group health plan that
has an enrollment period for late enrollees every November 1 through
November 30 with coverage effective the following January 1. On October
18, Individual B loses coverage under another group health plan and
satisfies the requirements of paragraphs (a)(2), (3), and (4) of this
section. B submits a completed application for coverage on November 2.
(ii) Conclusion. In this Example, B is a special enrollee.
Therefore, even though B's request for enrollment coincides with an open
enrollment period, B's coverage is required to be made effective no
later than December 1 (rather than the plan's January 1 effective date
for late enrollees).
[69 FR 78763, Dec. 30, 2004] 
