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- Health Benefits Advisor

Group Health Plan through My Spouse's Job

If certain conditions are met, you, your spouse and, in some cases, the children of you or your spouse, may have the opportunity for special enrollment as well as other enrollment opportunities in a group health plan offered by your spouse's employer, employee organization (such as a union), or both, even if your spouse is not presently enrolled in the plan and regardless of when the plan otherwise permits enrollment.

Qualifications for Special Enrollment

The following individuals may qualify for special enrollment in your spouse's group health plan if your spouse's plan provides coverage for dependents:

  1. Your spouse, if he or she is not already enrolled in the plan and is otherwise eligible.
  2. You, if the plan covers spouses and your spouse is already enrolled in the plan or enrolls with you.
  3. Children who become your spouse's dependents (as defined by the group health plan) as a result of the marriage, if the plan covers dependent children and your spouse is already enrolled in the plan, or your spouse enrolls in the plan with these children.

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 of the marriage date. 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 spouse's 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 you should:

  1. Read the notice of special enrollment rules that the plan was required to give your spouse when your spouse was 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 spouse's plan for information about enrollment rights; and
  3. Contact your state insurance department to find out if state law gives you or other family members additional enrollment rights.

How to Choose Among Health Coverage Options

Depending on your circumstances, you and your family members may have health coverage options available besides your spouse's group health plan. Before making any decisions, you should carefully consider information on your plan, any group health plan offered through your spouse's job, and other kinds of coverage for which you and your family members may qualify.

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) imposed 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 periods of health 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 marriage section and select another option.