Iowa Administrative Code › Agency 191 - Insurance Division › Life and Health Insurance › Chapter 35 - Accident and Health Insurance › Rule 191-35.25 - Special Enrollments

Current through Register Vol. 47, No. 3, July 24, 2024
(1) A
				carrier shall permit individuals to enroll for coverage under terms of a health
				benefit plan, without regard to other enrollment dates permitted under the
				group health insurance coverage, if an eligible employee requests enrollment
				or, if the group health insurance coverage makes coverage available to
				dependents, on behalf of a dependent who is eligible but not enrolled under the
				group health insurance coverage, during the special enrollment period, which
				shall be 30 days following an event described in subrule 35.25(2) or 35.25(3)
				with respect to the individual for whom enrollment is requested. A carrier may
				impose enrollment requirements that are otherwise applicable under terms of the
				group health insurance coverage to individuals requesting immediate
				enrollment.
(2) An individual, who
				previously had other coverage for medical care and for whom an eligible
				employee declined coverage under the group health insurance coverage, may be
				enrolled during a special enrollment period if the individual has lost the
				other coverage for medical care and:
a. If
				required by the group health insurance coverage, the eligible employee stated
				in writing when declining the coverage, after being given a notice of the
				requirement form, and the consequences of failure to submit a written statement
				that coverage was declined because the individual had coverage for medical care
				under another group health insurance coverage, group health plan, or otherwise;
				and
b. When enrollment was declined
				for the individual:
(1) The individual had
				coverage under a COBRA continuation provision and the coverage has been
				exhausted; or
(2) The individual
				had coverage other than under a COBRA continuation provision and the coverage
				has been terminated due to loss of eligibility for the coverage, including loss
				of coverage as a result of legal separation, divorce, death, termination of
				employment, reduction in the number of hours of employment and any loss of
				eligibility after a period that is measured by reference to any of the
				foregoing, or termination of employer contributions toward the other
				coverage.
c. For
				purposes of subparagraph 35.25(2)
"b"
(2):
(1) Loss of eligibility for the coverages
				does not include loss of eligibility due to the eligible employee's or
				dependent's failure to make timely premium payments or termination of coverage
				for cause such as making a fraudulent claim or intentional misrepresentation of
				material fact in connection with the group health insurance coverage;
				and
(2) Employer contributions
				include contributions by any current or former employer of the individual or
				another person that was contributing to coverage for the individual.
(3) Exhaustion of COBRA continuation coverage
				means that an individual's COBRA continuation coverage ceases for any reason
				other than either failure of the individual to pay premiums on a timely basis,
				or for cause, such as making a fraudulent claim or an intentional
				misrepresentation of a material fact in connection with the plan. An individual
				is considered to have exhausted COBRA continuation coverage if the coverage
				ceases.
(3) If the eligible
				employee has previously declined enrollment under the group health insurance
				coverage but acquires a dependent through marriage, birth, adoption or
				placement for adoption, the eligible employee or dependent may be enrolled
				during the special enrollment period with respect to the individual.
(4) Enrollment of the eligible employee or
				dependent is effective not later than the first day of the calendar month or,
				for a newborn or adopted child, on the date of birth, adoption, or placement
				for adoption.