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HIPAA Qualifying Event Indiana

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  • HIPAA Qualifying Event Indiana

    I am a school administrator and I am having difficulty adding my wife, child, and future child (due in January) to my insurance. The insurance package that I was offered when I began working for this school system was not any different than the plan that my wife currently had with the rest of my family. However, my school corporation has now given the school administrators are better plan and it is very beneficial for me to add my family. The old plan that I was on was a Plan III that was a high deductible plan that allowed for me to pay the first $6,000 per year in medical bills. The new plan has a deductible for my family of only $3,000 per year. I attempted to get my family on my insurance when the change was made, but I was informed that wasn't possible by my school insurance trust. My wife is now pregnant and due in January. I am again trying to add my family to my insurance once the child is born. The insurance trust tells me the birth of a child isn't a qualifying event. I looked through HIPAA documents this morning and I feel that I meet this criteria in a few different ways:

    1. Birth of a child
    2. Newly eligible dependents due to plan design change (I think the change in my plan III deductible would qualify, but I am not sure)
    3. Employment status--Commencement of, or return from, leave of absence (my wife is taking the last 4 months of the school year off)
    4. Loss of Coverage- My wife will be dropped to a COBRA insurance plan and will have to re-enroll next school year back to her old insurance plan. She will have to pay 100% of the premium after her FMLA is up.

    Would someone please let me know what they think about this situation?

  • #2
    When is the open enrollment for your plan?

    Birth of a child would qualify you to add that child but not the mom and a silbling.

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    • #3
      Open Enrollment

      They won't open enrollment up at all and allow for any changes. They used to do this, but they said that there were so many changes that they only let you choose at the time of employment and then you are stuck with your decision.

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      • #4
        Is your portion of the premium deducted from your paycheck pre-tax or post-tax? If post-tax, is there an option to have it done pre-tax?

        There is a reason for the question; your answer will impact what, if any, recourse you have.
        The above answer, whatever it is, assumes that no legally binding and enforceable contract or CBA says otherwise. If it does, then the terms of the contract or CBA apply.

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        • #5
          Pre-Tax

          My premium is $1 per year and it is taken pre tax.

          Comment


          • #6
            Not the question, but your employer is an idiot.
            "Reality is that which, when you stop believing in it, doesn't go away".
            Philip K. **** (1928-1982)

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            • #7
              I'll have to look up the exact reference and I'm sorry, but I won't have time to do so until after the holiday weekend.

              But my understanding is, if your deduction is pre-tax, they MUST have an open enrollment period.
              The above answer, whatever it is, assumes that no legally binding and enforceable contract or CBA says otherwise. If it does, then the terms of the contract or CBA apply.

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              • #8
                My understanding as well. Not the question, but I do not see the point in the employer involking the Section 125 rules in their entirety for the insignificant tax savings associated with making such a small annual deduction pre-tax. i do not think that IRS requires the employer to make a copy of the Section 125 plan to the employee, but it would be very interesting to read that particular plan document. Also be interesting to discover if the employer has actually bothered to read that plan document.

                Past that, all medical plans have a mandatory Summary Plan Document under the ERISA law, which the employer is required to give copies of to the employees on demand. Get a copy and read it. Just because some employer could have done something under ERISA does not mean that they have. Read the plan and see what the actual ERISA rules the employer is subject to are.
                "Reality is that which, when you stop believing in it, doesn't go away".
                Philip K. **** (1928-1982)

                Comment


                • #9
                  I am not an expert on this

                  I am not an expert on this, but I just don't understand what the issue is. Let me clarify, this is not my school system that is doing this. Our school system and some other local school systems belong to an insurance trust.

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                  • #10
                    I am very familiar with these kinds of plans but have never heard of one being a 125 plan before (aka, cafeteria plan, aka pre-tax). I have also never heard of not being able to opt in or out ever, for any reason, though the rules are usually different than for your typical cafeteria plan. It isn't clear who you talked to about this but make sure it is the person who actually administers the plan. Not a secretary or random co-worker.

                    There should also still be plan documents, which you are entitled to, and those documents should spell out when you can join or make changes.
                    I post with the full knowledge and support of my employer, though the opinions rendered are my own and not necessarily representative of their position. In other words, I'm a free agent.

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                    • #11
                      I will certainly defer to anything ElleMD has to say on this. I can give you a piece of an answer.
                      - ERISA/HIPAA/COBRA are all mandatory imposed laws administered by federal DOL. Your health care plan must have a Summary Plan Document, period, no exceptions, and you really need to read it. While some things are true for all employers, everyone's SPD is different and no one here can read your plan document for you.
                      - Section 125 is something very different. It is a voluntary (to the employer) program administered by IRS. Employers are not required to have a 125 plan, and they really are not required to have a really dumb plan. What you describe if accurate is a really dumb plan. The whole point of a 125 plan is to pay for certain employee deductions with pre-tax dollars. The problem is per you here is only $1/year in pre-tax dollars which will generate basically nothing in savings for the employee and the employer, but will generate serious costs on the employer to implement and manage the plan and the risk of very substantial penalties if the employer manages to mess things up. If what you describe is correct then I will stand by my prior statement that your employer is an idiot. The 125 plan is an entirely unrelated law to HIPAA with it's own unrelated rules. My understanding is that all of the 125 related deductions must be subject to change at least annually. But an 125 plan does not alter who is signed up for what health plan, it just effects the deductions. And a 125 plan can effect a lot more then just medical plan deductions. Most/all pre-tax deductions (other then deferrals) are generally 125 plan related. And it is perfectly legal to have a heatlh plan without having a 125 plan. Or visa-versa.
                      Last edited by DAW; 11-21-2012, 03:03 PM.
                      "Reality is that which, when you stop believing in it, doesn't go away".
                      Philip K. **** (1928-1982)

                      Comment


                      • #12
                        I concur entirely that if what you have stated is accurate, your employer is an idiot.
                        The above answer, whatever it is, assumes that no legally binding and enforceable contract or CBA says otherwise. If it does, then the terms of the contract or CBA apply.

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