Must a group health plan allow an individual to enroll if exchange coverage is lost?


Patricia, one of your customer service representatives, was enrolled in individual market health insurance coverage through the public health insurance exchange. She recently lost eligibility for that coverage and has asked to join your employer-sponsored group health plan. Is she entitled to a special enrollment period under your plan?


Yes. Employees and their dependents are eligible for special enrollment in a group health plan if they are otherwise eligible to enroll in the plan, and at the time coverage under the plan was previously offered, they had other group health plan or health insurance coverage (regardless of whether the coverage was obtained inside or outside of an exchange) for which they have lost eligibility.

Accordingly, if an individual loses eligibility for coverage in the individual market, including coverage purchased through an exchange (other than loss of eligibility for coverage due to failure to pay premiums on a timely basis or termination of coverage for cause, such as making a fraudulent claim or an intentional misrepresentation of a material fact), that individual is entitled to special enrollment in group health plan coverage for which he or she is otherwise eligible.

These individuals will be eligible for special enrollment in the group health plan coverage regardless of whether they may enroll in other individual market coverage, through or outside of an exchange.

Source: FAQs About Affordable Care Act Implementation, Part 35, December 20, 2016.

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