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Who can enroll when there’s a birth or adoption?

HIPAA says group health plans must give a special enrollment opportunity to newly acquired spouses and dependents, and also to current employees who had waived coverage before but have since acquired a new spouse or dependent. These special enrollment rights apply only if the new spouse or dependent is acquired by marriage, birth, adoption, or placement for adoption.

The rules say that the following individuals are considered “HIPAA special enrollees” and would be eligible to enroll upon gaining a new dependent due to birth, marriage, adoption, or placement for adoption:

  • a current employee who’s eligible but isn’t enrolled;

  • a current employee who’s eligible but not enrolled, and the spouse of this employee;

  • a current employee who’s eligible but not enrolled, and the new dependent of this employee;

  • the spouse of an employee who’s already a participant;

  • a current employee who’s eligible but not enrolled, and the spouse and new dependent; and

  • a new dependent of an employee who’s already a participant.

What this means is that HIPAA allows the employee and spouse to enroll upon birth or adoption of a child even if the employee and spouse weren’t previously enrolled. HIPAA is very clear that only the employee, spouse, and any newly acquired dependent receive special enrollment rights. Therefore, other dependents (such as siblings of a newborn child) aren’t entitled to special enrollment rights upon the employee's acquisition of a new dependent, unless the cafeteria plan allows tag-along enrollments of dependents who aren’t special enrollees.

For example, Joe is married to Jane and have two children, Max and Mimi. Joe, Jane, Max, and Mimi all are eligible for coverage under Joe’s employer's plan, but none of them are currently enrolled. Joe and Jane have a newborn child, Mike. Who can enroll upon the birth of baby Mike under HIPAA's special enrollment provisions?

  • Joe can enroll as employee-only coverage; or

  • Joe and Mike can enroll as employee + child; or

  • Joe and Jane can enroll as employee + spouse; or

  • Joe, Jane, and Mike can enroll as family coverage.

The employer’s plan doesn’t have to offer a special enrollment for Max and Mimi as a result of the birth of baby Mike, but the plan can accommodate the pre-existing dependents under the tag-along rule. But if the plan doesn’t allow a special enrollment for them, Joe would have to wait to enroll Max and Mimi during the plan's next open enrollment.

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