Eligibility
Change in Status Events and Rules

Print this page

Index

Click your Change in Status below to jump directly to the correct section.

  1. Change in Employee’s Legal Marital Status
    1. Gain Spouse (Marriage)
    2. Lose Spouse (Divorce, legal separation, annulment, or death of spouse)
  2. Change in the Number of Employee’s Dependents
    1. Gain Dependent (Birth, adoption, legal custody)
    2. Lose Dependent (Death, dependent no longer meets eligibility requirements)
  3. Change in Employment Status of Employee, Spouse, or Dependent that Affects Eligibility
    1. Commencement of Employment by Employee, Spouse, or Dependent (or Other Change in Employment Status) that Triggers Eligibility
      1. Commencement of employment by employee or other change in employment status (e.g., PT to FT) triggering eligibility under component plan
      2. Commencement of employment by spouse or dependent or other employment event triggering eligibility under their employer’s plan
    2. Termination of Employment by Employee, Spouse or Dependent (or Other Change in Employment Status) That Causes Loss of Eligibility
      1. Termination of employee’s employment or other change in employment status (e.g., unpaid leave, FT to PT) resulting in loss of eligibility
        1. Termination of rehire within 30 days
        2. Termination and rehire after 30 days
      2. Termination of spouse’s or dependent’s employment (or other change in employment status resulting in a loss of eligibility under their employer’s plan)
  4. Event Causing Employee’s Dependent to Satisfy Eligibility Requirements
    1. Event by which dependent ceases to satisfy eligibility requirements under another employer’s plan (attaining a specified age, getting married, ceasing to be a student, etc.)
  5. Change in Place of Residence of Employee, Spouse, or Dependent
    1. Move triggers eligibility
    2. Move causes loss of eligibility (e.g. employee or dependent moves outside HMO service area)
  6. Change in Coverage Under Other Employer Cafeteria Plan or Qualified Benefits Plan
    1. Other employer plan increases coverage
    2. Other employer’s plan decreases or ceases coverage
    3. Open Enrollment under other employer plan/ different year
    4. Loss of group health coverage sponsored by Governmental or Educational Institution
  7. Florida Kidcare, Medicaid, Medicare or TRICARE
    1. Employee, spouse, or dependent enrolled in employer’s health plan become entitled to Medicare or Medicaid (other than coverage solely for pediatric vaccines)
    2. Employee, spouse, or dependent loses eligibility for Medicare or Medicaid (other than coverage solely for pediatric vaccines.
  8. FMLA Leaves of Absence
    1. Employee’s commencement of FMLA leave
    2. Employee’s return from FMLA leave
  9. Judgment, Decree or Orders
    1. Order that requires coverage for the child under employee’s plan
    2. Order that requires spouse, former spouse or other individual to provide coverage for the child
  10. HIPAA Special Enrollment Rights
    1. Special enrollment for loss of other coverage.
    2. Special enrollment for acquisition of new dependent by birth, marriage, adoption or placement for adoption. (If newborn or newlyadopted child is enrolled under HIPAA’s special rules, child’s coverage may be retroactive to date of birth, adoption or placement for adoption; employee may change salary reduction election within 30 days to pay for cost of child’s coverage retroactive to date of birth, adoption or placement for adoption. (For marriage, salary reductions may only be changed prospectively.)

A. Change in Employee’s Legal Marital Status

A.1 Gain Spouse (Marriage)

  • Supporting Document
    • Marriage Certificate; AND
    • Recent IRS Tax Return required (if married prior to current calendar year)
  • Medical
    • Employee may enroll or increase election for newly eligible spouse and dependent children as well as pre- existing dependents; employee may also revoke or decrease own or dependent’s coverage only when such coverage becomes effective or is increased under the spouse’s plan. HIPAA special enrollment rights may also apply.
  • Dental and Vision
    • Employee may enroll or increase election for newly eligible spouse and dependent children as well as pre- existing dependents; employee may also revoke or decrease own or dependent’s coverage only when such coverage becomes effective or is increased under the spouse’s plan. HIPAA special enrollment rights may also apply.
  • Health FSA
    • Employee may enroll or increase election for newly eligible spouse and dependents; employee may also decrease election if employee or dependents become eligible under new spouse’s health plan.
  • Dependent Care FSA
    • Employee may enroll or increase election for newly eligible spouse and dependents; employee may also decrease election if employee or dependents become eligible under new spouse’s Dependent Care FSA plan; or, employee may cease coverage if new spouse is not employed or makes a Dependent Care FSA coverage election under spouse’s plan.
  • Employee Group Term Life and AD&D
    • Employee may enroll in coverage when eligibility is affected

A.2 Lose Spouse (Divorce, legal separation, annulment, or death of spouse)

  • Supporting Document
    • Divorce Decree
    • Court documentation stating legally separated
      or marriage annulled
    • Death certificate
  • Medical
    • Employee may revoke election only for spouse; employee may also elect coverage for self or dependents that lose eligibility under spouse’s plan if such individual loses eligibility; employee may also enroll new and pre-existing dependents so long as at least one dependent has lost coverage under the spouse’s plan. HIPAA special enrollment rights may also apply.
  • Dental and Vision
    • Employee may revoke election only for spouse; employee may also elect coverage for self or dependents that lose eligibility under spouse’s plan if such individual loses eligibility; employee may also enroll new and pre-existing dependents so long as at least one dependent has lost coverage under the spouse’s plan. HIPAA special enrollment rights may also apply.
  • Health FSA
    • Employee may decrease election to reflect loss of spouse’s eligibility; employee may also enroll or increase election where coverage is lost under spouse’s health plan.
  • Dependent Care FSA
    • Employee may enroll or increase election to accommodate newly eligible dependents (e.g., due to death of spouse); employee may also cease coverage if eligibility is lost (e.g., because dependent now resides with ex- spouse).
  • Employee Group Term Life and AD&D
    • Employee may cease coverage when eligibility is affected

B. Change in the Number of Employee’s Dependents

B.1 Gain Dependent (Birth, adoption, legal custody)

  • Supporting Document
    • Birth Certificate or Hospital Certificate with Footprints
    • Adoptions papers or placement for adoption papers
    • Legal custody papers
    • Marriage certificate – if spouse (not employee ) is legal guardian/ adoptive parent/ custodian / foster parent
  • Medical
    • Employee may enroll or increase election for newly eligible dependents and/or enroll any pre-existing dependents; employee may also revoke or decrease own or dependent’s coverage if employee or dependent become eligible under spouse’s plan. HIPAA special enrollment rights may also apply
  • Dental and Vision
    • Employee may enroll or increase election for newly eligible dependents and/or enroll any pre-existing dependents; employee may also revoke or decrease own or dependent’s coverage if employee or dependent become eligible under spouse’s plan. HIPAA special enrollment rights may also apply
  • Health FSA
    • Employee may enroll or increase election for newly eligible dependents and/or enroll any pre-existing dependents; employee may also revoke or decrease own or dependent’s coverage if employee or dependent become eligible under spouse’s plan. HIPAA special enrollment rights may also apply
  • Dependent Care FSA
    • Employee may enroll or increase election to accommodate newly eligible dependents and any other non- covered dependents
  • Employee Group Term Life and AD&D
    • Employee may increase coverage when eligibility is affected

B.2 Lose Dependent (Death, dependent no longer meets eligibility requirements)

  • Supporting Document
    • Death certificate
  • Medical
    • Employee may drop coverage only for the dependent who loses eligibility
  • Dental and Vision
    • Employee may drop coverage only for the dependent who loses eligibility
  • Health FSA
    • Employee may drop coverage only for the dependent who loses eligibility
  • Dependent Care FSA
    • Employee may decrease election for dependent who lost eligibility
  • Employee Group Term Life and AD&D
    • Employee may decrease or cease coverage even when eligibility is not affected

C. Change in Employment Status of Employee, Spouse, or Dependent that Affects Eligibility

C.1 Commencement of Employment by Employee, Spouse, or Dependent (or Other Change in Employment Status) that Triggers Eligibility

C.1.a Commencement of employment by employee or other change in employment status (e.g., PT to FT) triggering eligibility under component plan

  • Supporting Document
    • Letter from employer verifying employment status change
  • Medical
    • Provided eligibility was gained for this coverage, employee may add coverage for employee, spouse, or dependents
  • Dental and Vision
    • Provided eligibility was gained for this coverage, employee may add coverage for employee, spouse, or dependents
  • Health FSA
    • Provided eligibility was gained for this coverage, employee may add coverage for employee, spouse, or dependents
  • Dependent Care FSA
    • Provided eligibility was gained for this coverage, employee may add coverage for employee, spouse, or dependents
  • Employee Group Term Life and AD&D
    • No change permitted

C.1.b Commencement of employment by spouse or dependent or other employment event triggering eligibility under their employer’s plan

  • Supporting Document
    • Letter from employer verifying employment event triggering eligibility under the employer’s plan
  • Medical
    • Employee may revoke or decrease election under employee’s, spouse’s, or dependent’s coverage if employee, spouse or dependent is added to spouse’s or dependent’s coverage
  • Dental and Vision
    • Employee may revoke or decrease election under employee’s, spouse’s, or dependent’s coverage if employee, spouse or dependent is added to spouse’s or dependent’s coverage
  • Health FSA
    • Employee may decrease or cease election if he or she gains eligibility for health coverage under spouse’s or dependent’s plan
  • Dependent Care FSA
    • Employee may make or increase election to reflect new eligibility (e.g., if spouse previously did not work); employee may also revoke election for dependent’s coverage if dependent is added to spouse’s plan
  • Employee Group Term Life and AD&D
    • No change permitted

C.2 Termination of Employment by Employee, Spouse or Dependent (or Other Change in Employment Status) That Causes Loss of Eligibility

C.2.a Termination of employee’s employment or other change in employment status (e.g., unpaid leave, FT to PT) resulting in loss of eligibility

  • Supporting Document
    • Letter from employer verifying employment termination or employment status change
  • Medical
    • Employee may revoke or decrease election for employee, spouse or dependent that loses eligibility under the plan
  • Dental and Vision
    • Employee may revoke or decrease election for employee, spouse or dependent that loses eligibility under the plan
  • Health FSA
    • Employee may revoke election to reflect loss of eligibility (note that under most health FSAs, employee loses coverage automatically)
  • Dependent Care FSA
    • Employee may revoke or decrease election to reflect loss of eligibility
  • Employee Group Term Life and AD&D
    • Employee may revoke or decrease election to reflect loss of eligibility
C.2.a.i Termination of rehire within 30 days
  • Supporting Document
    • Letter from employer verifying employment termination
  • Medical
    • Prior elections at termination are reinstated unless another event has occurred that allows a change
  • Dental and Vision
    • Prior elections at termination are reinstated unless another event has occurred that allows a change
  • Health FSA
    • Prior elections at termination are reinstated unless another event has occurred that allows a change
  • Dependent Care FSA
    • Prior elections at termination are reinstated unless another event has occurred that allows a change
  • Employee Group Term Life and AD&D
    • Prior elections at termination are reinstated unless another event has occurred that allows a change
C.2.a.ii Termination and rehire after 30 days
  • Supporting Document
    • Letter from employer verifying employment termination and rehire
  • Medical
    • Employee may make new elections
  • Dental and Vision
    • Employee may make new elections
  • Health FSA
    • Employee may make new elections
  • Dependent Care FSA
    • Employee may make new elections
  • Employee Group Term Life and AD&D
    • Employee may make new elections

C.2.b Termination of spouse’s or dependent’s employment (or other change in employment status resulting in a loss of eligibility under their employer’s plan)

  • Supporting Document
    • Letter from employer verifying employment event triggering eligibility under the employer’s plan
  • Medical
    • Employee may enroll or increase election for employee, spouse or dependent that loses eligibility under spouse’s or dependent’s employer’s plan; employee may also enroll previously eligible dependents. HIPAA special enrollment rights may also apply
  • Dental and Vision
    • Employee may enroll or increase election for employee, spouse or dependent that loses eligibility under spouse’s or dependent’s employer’s plan; employee may also enroll previously eligible dependents. HIPAA special enrollment rights may also apply
  • Health FSA
    • Employee may enroll or increase election to reflect loss of eligibility for health coverage
  • Dependent Care FSA
    • Employee may enroll or increase election if spouse or dependent loses eligibility for Dependent Care FSA; employee may also decrease or cease election to reflect loss of eligibility for coverage (e.g., if spouse stops working)
  • Employee Group Term Life and AD&D
    • No change permitted

D. Event Causing Employee’s Dependent to Satisfy Eligibility Requirements

D.1 Event by which dependent ceases to satisfy eligibility requirements under another employer’s plan (attaining a specified age, getting married, ceasing to be a student, etc.)

  • Supporting Document
    • Letter from employer indicating dependent no longer meets eligibility requirements
  • Medical
    • Employee may enroll or increase election for affected dependent, employee may also add previously eligible but not enrolled dependents
  • Dental and Vision
    • Employee may enroll or increase election for affected dependent, employee may also add previously eligible but not enrolled dependents
  • Health FSA
    • Employee may increase election or enroll only if dependent gains eligibility under health FSA
  • Dependent Care FSA
    • Employee may increase election or enroll to take into account expenses of affected dependent
  • Employee Group Term Life and AD&D
    • No change permitted

E. Change in Place of Residence of Employee, Spouse, or Dependent

E.1 Move triggers eligibility

  • Supporting Document
    • Documentation of the move
  • Medical
    • A change in the place of residence of the employee, spouse or dependent that affects eligibility to be covered under an employer’s plan includes moving out of an HMO service area
  • Dental and Vision
    • A change in the place of residence of the employee, spouse or dependent that affects eligibility to be covered under an employer’s plan includes moving out of an HMO service area
  • Health FSA
    • A change in the place of residence of the employee, spouse or dependent that affects eligibility to be covered under an employer’s plan includes moving out of an HMO service area
  • Dependent Care FSA
    • N/A – Dependent Care FSA eligibility is not generally affected by place of resident
  • Employee Group Term Life and AD&D
    • No change permitted

E.2 Move causes loss of eligibility (e.g. employee or dependent moves outside HMO service area)

  • Supporting Document
    • Documentation of the move
  • Medical
    • A change in the place of residence of the employee, spouse or dependent that affects eligibility to be covered under an employer’s plan includes moving out of an HMO service area
  • Dental and Vision
    • A change in the place of residence of the employee, spouse or dependent that affects eligibility to be covered under an employer’s plan includes moving out of an HMO service area
  • Health FSA
    • A change in the place of residence of the employee, spouse or dependent that affects eligibility to be covered under an employer’s plan includes moving out of an HMO service area
  • Dependent Care FSA
    • N/A – Dependent Care FSA eligibility is not generally affected by place of resident
  • Employee Group Term Life and AD&D
    • No change permitted

F. Change in Coverage Under Other Employer Cafeteria Plan or Qualified Benefits Plan

F.1 Other employer plan increases coverage

  • Supporting Document
    • Letter from employer verifying coverage increase
  • Medical
    • Employee may decrease or revoke election for employee, spouse, or dependents if employee, spouse, or dependents have elected or received corresponding increased coverage under another employer plan.
  • Dental and Vision
    • Employee may decrease or revoke election for employee, spouse, or dependents if employee, spouse, or dependents have elected or received corresponding increased coverage under another employer plan.
  • Health FSA
    • No change permitted
  • Dependent Care FSA
    • No change permitted
  • Employee Group Term Life and AD&D
    • No change permitted

F.2 Other employer’s plan decreases or ceases coverage

  • Supporting Document
    • Letter from employer verifying decrease or cease of coverage
  • Medical
    • Employee may enroll or increase election for employee, spouse, or dependents if employee, spouse, or dependents have elected or received corresponding decreased coverage under other employer plan
    • Other previously eligible dependents may be enrolled
  • Dental and Vision
    • Employee may enroll or increase election for employee, spouse, or dependents if employee, spouse, or dependents have elected or received corresponding decreased coverage under other employer plan
    • Other previously eligible dependents may be enrolled
  • Health FSA
    • No change permitted
  • Dependent Care FSA
    • No change permitted
  • Employee Group Term Life and AD&D
    • No change permitted

F.3 Open Enrollment under other employer plan/ different year

  • Supporting Document
    • Letter from employer verifying open enrollment
  • Medical
    • Corresponding changes can be made under employer’s plan permitted
  • Dental and Vision
    • Corresponding changes can be made under employer’s plan permitted
  • Health FSA
    • No change permitted
  • Dependent Care FSA
    • No change permitted
  • Employee Group Term Life and AD&D
    • No change permitted

F.4 Loss of group health coverage sponsored by Governmental or Educational Institution

  • Supporting Document
    • Letter from Governmental or Educational Institution verifying loss of group health coverage
    • Certificate of Creditable Coverage
  • Medical
    • Employee may enroll or increase election for employee, spouse, or dependent if employee, spouse, or dependent loses group health coverage sponsored by governmental or educational institution
  • Dental and Vision
    • Employee may enroll or increase election for employee, spouse, or dependent if employee, spouse, or dependent loses group health coverage sponsored by governmental or educational institution
  • Health FSA
    • No change permitted
  • Dependent Care FSA
    • No change permitted
  • Employee Group Term Life and AD&D
    • No change permitted

G. Florida Kidcare, Medicaid, Medicare or TRICARE

G.1 Employee, spouse, or dependent enrolled in employer’s health plan become entitled to Medicare or Medicaid (other than coverage solely for pediatric vaccines)

  • Supporting Document
    • Letter from Florida Kidcare, Medicaid, Medicare or TRICARE verifying enrollment
    • Florida Kidcare, Medicaid, Medicare or TRICARE ID card reflecting effective date of coverage
  • Medical
    • Employee may cancel or reduce coverage for employee, spouse, or dependent as applicable
  • Dental and Vision
    • Employee may cancel or reduce coverage for employee, spouse, or dependent, as applicable
  • Health FSA
    • Employee may decrease or revoke election under employer plan
  • Dependent Care FSA
    • No change permitted
  • Employee Group Term Life and AD&D
    • No change permitted

G.2 Employee, spouse, or dependent loses eligibility for Medicare or Medicaid (other than coverage solely for pediatric vaccines.

  • Supporting Document
    • Letter from Florida Kidcare, Medicaid, Medicare or TRICARE verifying loss of eligibility.
  • Medical
    • Employee may elect to commence or increase coverage for employee, spouse, or dependent, as applicable and add previously eligible (but not yet enrolled) dependents.
  • Dental and Vision
    • Employee may cancel or reduce coverage for employee, spouse, or dependent, as applicable
  • Health FSA
    • Employee may commence or increase election under employer plan
  • Dependent Care FSA
    • No change permitted
  • Employee Group Term Life and AD&D
    • No change permitted

H. FMLA Leaves of Absence

H.1 Employee’s commencement of FMLA leave

  • Supporting Document
    • Documentation verifying employee is on LOA
  • Medical
    • Employee can make same election changes as employee on non-FMLA leave. Employer must allow employee on unpaid FMLA leave either to revoke coverage or to continue coverage, but allow employee to discontinue payment of his or her share of the contribution during the leave. The employer may recover the employee’s share of contributions when the employee returns to work
  • Dental and Vision
    • Employee can make same election changes as employee on non-FMLA leave. Employer must allow employee on unpaid FMLA leave either to revoke coverage or to continue coverage, but allow employee to discontinue payment of his or her share of the contribution during the leave. The employer may recover the employee’s share of contributions when the employee returns to work
  • Health FSA
    • Employee can make same election changes as employee on non-FMLA leave. Employer must allow employee on unpaid FMLA leave either to revoke coverage or to continue coverage, but allow employee to discontinue payment of his or her share of the contribution during the leave. The employer may recover the employee’s share of contributions when the employee returns to work
    • Upon return, employee whose coverage has lapsed has the right to resume coverage at prior coverage level (and make up unpaid premiums)
  • Dependent Care FSA
    • Employee may make a new election if coverage terminated while on FMLA leave. Employer may require an employee to be reinstated in his or her election upon return from leave if employees who return from non-FLA leave are required to be reinstated in their elections.
  • Employee Group Term Life and AD&D
    • Employee may make a new election if coverage terminated while on FMLA leave. Employer may require an employee to be reinstated in his or her election upon return from leave if employees who return from non-FLA leave are required to be reinstated in their elections.

H.2 Employee’s return from FMLA leave

  • Supporting Document
    • N/A
  • Medical
    • Employee may make a new election if coverage terminated while on FMLA leave. In addition, an employer may require an employee to be reinstated in his or her election upon return from leave if employees who return from a non-FMLA leave are required to be reinstated in their elections
  • Dental and Vision
    • Employee may make a new election if coverage terminated while on FMLA leave. In addition, an employer may require an employee to be reinstated in his or her election upon return from leave if employees who return from a non-FMLA leave are required to be reinstated in their elections
  • Health FSA
    • Employee may make a new election if coverage terminated while on FMLA leave. In addition, an employer may require an employee to be reinstated in his or her election upon return from leave if employees who return from a non-FMLA leave are required to be reinstated in their elections
    • Upon return, employee whose coverage has lapsed has the right to resume coverage at prior coverage level (and make unpaid premiums)
  • Dependent Care FSA
    • Employee may make a new election if coverage terminated while on FMLA leave. In addition, an employer may require an employee to be reinstated in his or her election upon return from leave if employees who return from a non-FMLA leave are required to be reinstated in their elections
  • Employee Group Term Life and AD&D
    • Employee may make a new election if coverage terminated while on FMLA leave. In addition, an employer may require an employee to be reinstated in his or her election upon return from leave if employees who return from a non-FMLA leave are required to be reinstated in their elections

I. Judgment, Decree or Orders

I.1 Order that requires coverage for the child under employee’s plan

  • Supporting Document
    • Court order
  • Medical
    • Employee may change election to provide coverage for the child. Though unclear, it appears tag-along rule concepts may apply
  • Dental and Vision
    • Employee may change election to provide coverage for the child. Though unclear, it appears tag-along rule concepts may apply
  • Health FSA
    • No Change
  • Dependent Care FSA
    • No Change
  • Employee Group Term Life and AD&D
    • No Change

I.2 Order that requires spouse, former spouse or other individual to provide coverage for the child

  • Supporting Document
    • Court order
  • Medical
    • Employee may change election to cancel coverage for the child provided the child is enrolled in the plan of the spouse, former spouse or other individual required to provide coverage
  • Dental and Vision
    • Employee may change election to cancel coverage for the child provided the child is enrolled in the plan of the spouse, former spouse or other individual required to provide coverage
  • Health FSA
    • No Change
  • Dependent Care FSA
    • No Change
  • Employee Group Term Life and AD&D
    • No Change

J. HIPAA Special Enrollment Rights

J.1 Special enrollment for loss of other coverage

  • Supporting Document
    • N/A
  • Medical
    • Employee may elect coverage for employee, spouse, or dependent who lost other coverage. Though unclear, it appears that tag-along concepts may apply
  • Dental and Vision
    • Employee may elect coverage for employee, spouse, or dependent who lost other coverage. Though unclear, it appears that tag-along concepts may apply
  • Health FSA
    • Same as health insurance if plan is subject to HIPAA portability rules
  • Dependent Care FSA
    • No Change
  • Employee Group Term Life and AD&D
    • No Change

J.2 Special enrollment for loss of other coverage

  • Supporting Document
    • N/A
  • Medical
    • Employee may elect coverage for employee, spouse, or dependent. Under the tag-along rule, coverage may also extend to previously eligible (but not yet enrolled) dependents
  • Dental and Vision
    • Employee may elect coverage for employee, spouse, or dependent. Under the tag-along rule, coverage may also extend to previously eligible (but not yet enrolled) dependents
  • Health FSA
    • No change permitted unless plan is subject to HIPAA
  • Dependent Care FSA
    • No Change
  • Employee Group Term Life and AD&D
    • No Change