In general, members of pre-tax group health plans can only change benefits once a year during the open enrollment period, as outlined in Section 125 of the Internal Revenue Code.
The exception to this rule is a special enrollment period known as a qualifying life event (QLE). Through QLEs, the IRS provides specific instances when employees can evaluate and change their elections mid-year to adjust for life’s changes.
QLE details are listed in your company’s Summary Plan Description (SPD) documents.
Common qualifying life events:
- Marriage or divorce
- Having a baby or adopting a child
- Death in the family, such as a covered member or eligible dependent
- Change in employment status
- Loss of existing health coverage
- Loss of Medicare, Medicaid, or CHIP eligibility
- Loss of coverage through a parent’s plan (typically on 26th birthday)
- Medicare eligibility (typically on 65th birthday or annual Open Enrollment)
- Changes in household or residence
- Becoming a U.S. citizen
- Starting or ending AmeriCorps service
- Becoming a member of a federally recognized tribe or an Alaska Native Claims Settlement Act (ANCSA) Corporation shareholder
If the employee is eligible for benefits and has satisfied the company’s established waiting period, they have 31 days after the qualifying event to request a change.
- Refer the employee to our Member Help Center article on Qualifying Life Events. Here they will find instructions on submitting changes from their Sana account. Reminder: Employees have 31 days after a QLE to make updates.
- Once the employee has updated their elections, the QLE will appear as a pending enrollment in your admin dashboard.
- Visit the admin dashboard to review and approve pending enrollments.
- Once approved, benefits will start or end on the date of the QLE.
- Sana does not prorate premiums.
- QLE changes cannot be made/requested before the event happens. Changes can only be made on the day of the event or within the 31 days following the event.
- If your employee was not previously eligible for benefits, they are required to satisfy the company’s waiting period prior to coverage. For example, if a part-time employee moves to full-time, the coverage start date is calculated using the full-time employment date. Follow the steps for adding a new hire to begin their enrollment process.