An employer must submit the initial application by the 15th of the month for coverage to take effect by the 1st of the following month.
In some cases, an individual becomes a “newly qualified employee” outside of the initial or annual open enrollment period (either as a new hire or due to other changes in circumstances, such as a change from part-time to full-time status).
In these situations, the SHOPs will provide the individual with an enrollment period that will allow coverage to begin on the first day of the month after becoming a qualified employee.
Under certain circumstances, employees may enroll in or change QHPs outside of the annual open enrollment period. These SEPs are based on certain triggering events.
In general, the SHOP SEPs are based on the same triggering events that result in SEPs in the Individual (i.e., non-SHOP) Marketplace (except for changes that are not relevant to SHOP, such as changes in citizenship status, or eligibility for premium tax credits).
In most cases, SEPs last for 30 days from the date of the triggering event. Individuals who do not take action by this deadline will have to wait until the annual open enrollment period to join a plan
Events that permit SEPs include, but are not limited to:
As mentioned, a SEP exists for marriage. This means that, if a qualified employee gets married, he or she has the chance to either enroll in a QHP for the first time, or add a spouse to the plan without waiting for the annual open enrollment period.
The SHOP would need to be notified within 30 days of a marriage for a spouse to be covered. If the 30-day deadline is missed, the spouse cannot enroll until the plan's annual open enrollment period.
Another important SEP exists for the birth or adoption of a child.
The effective date of coverage can be the date of the birth or the official date of adoption as long as the SHOP is notified in a timely manner.
The SHOP would need to be notified within 30 days of a birth or adoption for dependents to be covered. If the 30-day deadline is missed, the dependents cannot be enrolled until the plan's annual open enrollment period.
Premiums would be pro-rated for the month, based on when the child was added to the policy.
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