Eligibility and Enrollment
How To Choose A Plan
Proof Of Eligibility Requirements
Initial Enrollment (new hire)
You are eligible to enroll in the Plan if you work for a participating employer and you are a member of a group of employees designated by your participating employer as eligible to participate.
To enroll in the Plan, you must complete the Enrollment/Change Form and return to your Human Resources department within 31 calendar days after your hire date.
In order to be eligible for coverage under the OHP Medical Plan, any spouse of an eligible employee who has coverage available through an employer-sponsored group health plan or retiree plan must join that plan on at least a single enrollment basis. If you enroll your spouse as a dependent, you must also complete the Spousal/Other Coverage form and return to EBMC so they can coordinate benefits with your spouse’s employer-sponsored group health plan.
Annual Open Enrollment
Each year you have the opportunity to participate in the Medical plan for the first time, change plan options or add or drop dependents without a qualifying event. Your must participate in open enrollment to enroll or make a change. Open enrollment occurs in the fall of each year with coverage effective January 1 of the following year.
Family Status Changes, Qualifying Events, District Enrollment Contacts
When family status changes occur, the last thing on your mind is to update your employer of these changes. However, failure to notify your employer may cause your medical claim payments to be delayed or denied. Also, your rights to enroll in the plan or continue coverage may expire. Notify your Human Resources on the enrollment/change form of the following changes within 31 days of the qualifying event:
- Loss of medical coverage due to:
- Spouse’s coverage ends with employer due to termination or reduction of hours
- COBRA exhausted
- Qualified Medical Child Support Order
- Child turns 26 on medical or dental plan
- Child gets married
- Address or phone number change
Special provision: Newborns are covered at the moment of birth ONLY if you enroll your new baby in the plan within 31 days immediately following birth.
Your medical claim payments may be delayed or denied if you do not notify your Human Resources or Benefits Department.
When Coverage Can Be Added Or Terminated
In general you cannot change or drop your health benefits unless it is done during the plan’s annual Open Enrollment, or you experience a qualifying event and make the change within 31 days of the event.
Open Enrollment Period:
Each year, a period of time may be designated as an Open Enrollment period. Except for Special Enrollment or Late Enrollment, if applicable, it is only during this period that an Employee or Dependent who did not enroll during their initial eligibility period may enroll or drop coverage in a Plan.
Qualifying events include but are not limited to the following:
- Death of a spouse
- Legal separation
- Birth, adoption, placement for adoption or death of a dependent
- Termination or commencement of employment of a spouse
- A dependent or spouse fail to satisfy the plan’s definition of an eligible dependent or spouse
- Loss of eligibility which includes a loss of coverage due to:
- Legal separation;
- Termination of employment, or reduction in hours of employment;
- Relocating outside of a HMO’s service area (only if there is no access to other coverage through the HMO);
- A plan no longer offering benefits to a class of similarly situated individuals even if the plan continues to provide coverage to other individuals;
- The Employee or Dependent is covered under a Medicaid plan or under a state CHIP program, and coverage of the employee or dependent under such plan/program is terminated as a result of loss of eligibility for such coverage.
Remember that your health plan allows you to have your premiums deducted pre-tax. As a result the plan is considered a “cafeteria plan”, and is subject to IRS cafeteria plan regulations. Under these regulations employees cannot drop coverage at any time unless is during the plan’s open enrollment period, or within 31 days of a status change or qualifying event.
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