Iowa Administrative Code › Agency 191 - Insurance Division › Health Benefit Plans › Chapter 71 - Small Group Health Benefit Plans* › Rule 191-71.18 - 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 plan, if an eligible employee requests enrollment or, if the group
				health plan makes coverage available to dependents, on behalf of a dependent
				who is eligible but not enrolled under the group health plan, during the
				special enrollment period, which shall be 30 days following an event described
				in subrules 71.18(2) and 71.18(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 plan 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 plan, 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 plan, 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 plan or otherwise;
				and
b. When enrollment was declined
				for the individual:
(1) The individual had
				coverage other than 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 this subparagraph 71.18(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 plan; 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.