Skip to Main Content

elaws - employment laws assistance for workers and small businesses

- Health Benefits Advisor

Group Health Plan through My Spouse

If certain conditions are met, you, your spouse and your dependent children may have the opportunity for special enrollment as well as other enrollment opportunities in your spouse's group health plan, regardless of when the plan otherwise permits enrollment.

Qualifications for Special Enrollment

You may qualify for special enrollment in your spouse's group health plan if:

  1. You are otherwise eligible for coverage;
  2. You were covered under your plan when enrollment in your spouse's plan was previously offered and declined;
  3. You became ineligible for coverage under your plan because your hours were reduced; and
  4. Your spouse is enrolled in his or her plan or enrolls with you.

You may also qualify for special enrollment in your spouse's group health plan if you enroll with your spouse or dependent children who have a special enrollment right.

Your spouse may qualify for special enrollment in his or her group health plan if your spouse is otherwise eligible for coverage.

Your dependent children may also qualify for special enrollment in your spouse's group health plan (even if you do not enroll) if:

  1. The children are otherwise eligible for coverage;
  2. The children were covered under your plan when enrollment under the spouse's plan was previously offered and declined;
  3. The children became ineligible for coverage under your plan because your hours were reduced; and
  4. Your spouse is enrolled in his or her plan or enrolls with the children.

Your dependent children may also qualify for special enrollment in your spouse's group health plan if they enroll with you or your spouse and you or your spouse has a special enrollment right.

Time Frames for Special Enrollment

In order to special enroll in your spouse's group health plan, your spouse must request the enrollment within 30 days after termination of coverage under your spouse's group health plan. If special enrollment is properly requested:

  1. The plan must make the enrollment effective no later than the first day of the first month after the plan receives the request; and
  2. The plan may not apply a pre-existing condition exclusion of more than 12 months. Also, the plan generally must shorten any pre-existing condition exclusion period by the number of days of prior coverage that each person had.

NOTE: Even if you or your family members decide not to special enroll in your plan, it is important to try to avoid incurring a significant break in coverage, especially if you or a family member has a pre-existing condition. A significant break in coverage is a period of 63 consecutive days (or longer in some states) without health coverage. Only prior health coverage that was not interrupted by a significant break in coverage is required to be applied to shorten a pre-existing condition exclusion period. In addition, you and your family members may later qualify to buy coverage with special protections in your state if you and your family members had 18 months of coverage without a significant break and meet other conditions. Contact your state insurance department for more information.

Additional Enrollment Rights

In addition to the special enrollment rights just described, you and your family members may have other rights to enroll in your spouse's group health plan. Additional rights to enroll may exist under the terms of your spouse's group health plan or under state law.

To find out more about enrollment rights in your spouse's group health plan:

  1. Read the notice of special enrollment rules that the plan was required to give you when you were offered the opportunity to enroll in the plan. The plan may (but is not required to) use a model description of special enrollment rules;
  2. Review the SPD (summary plan description) of your plan for information about enrollment rights; and
  3. Contact your state insurance department to find out if state laws give you or other family members additional enrollment rights.

How to Choose Among Health Coverage Options

Depending on your circumstances, you, your spouse and your dependent children may have health coverage options available besides your spouse's group health plan. Before making any decisions, you should carefully consider information on your spouse's plan, as well as other kinds of coverage for which you and your family members may qualify. To learn about your spouse's group health plan, review the plan's SPD.

In choosing among the options available to you, you should review the SPD for each available group health plan to determine which plan best meets your needs. You should also review and compare the information on the other coverages for which you are eligible. In making your decision, you may want to consider such things as:

  1. Any waiting period (or affiliation period) under the plans;
  2. Types of benefits offered (Is dependent coverage available? Do the benefits cover your family's medical needs?);
  3. Cost of coverage (premiums, co-payments and deductibles for prescription drugs and doctor visits);
  4. Limitations on coverage (annual or lifetime dollar limits, visit limits, pre-existing condition exclusion periods, prescription drug coverage limits or limits on the availability of doctors and hospitals); and
  5. Any exclusions from coverage (treatments, procedures, conditions or prescription drugs).

Remember, it is IMPORTANT to avoid a significant break between your old and new coverage, especially for anyone who has a pre-existing condition.

To find out about other kinds of health coverage for which you and your family members may qualify, return to the beginning of the Reduction in Hours section and select another option.