Qualifying Events

[Prieta]

I'm new to HR in New York and I know what a qualifying event is. My questions is this: can someone change medical providers under the qualifying act? Or can they just add and drop within the current medical provider?

[cbg]

They can change medical providers whenever the plan permits it. They do not need a qualifying event to change medical providers.

[Prieta]

Thanks for the response. Are you referring to "Open Enrollment" ? I've been through two so far so I understand how that works. I guess I'm not posing the question properly...during your qualifying event (excluding open enrollment) can you switch providers? The ongoing census is "no" but we were recently informed by a sister company that you can. I have at least 3 HR contacts from other companies and they also have said "no" and this one particular person said "yes" which worries me. Have we been saying no to our employees all along and were wrong? Perhaps a new law was just implemented?

[cbg]

Unless your insurance policy specifically says otherwise, you can switch medical providers whenever you like. Nothing in the law requires an employee to have a qualifying event before they can change doctors or hospitals. This has always been the case - there has been no change in the law. Whoever is telling you that you cannot change medical providers except during Open Enrollment is wrong.

Edited to include:

It just occurred to me where the confusion may be coming from. Let's be clear. When you say, medical providers, do you mean doctors, hospitals, pharmacists etc,(Dr. Smith, Dr. Jones, University Hospital) or do you mean INSURANCE providers (Aetna, United Health Care, Blue Cross Blue Shield, etc.)

[Prieta]

Yes! That's it! I mean insurance providers. Terms are used so loosley at my company, sorry for the confusion. We do not allow changes from--for example--Oxford Health Plan to Aetna HMO during qualifying events. Are we correct in doing this?

[cbg]

That's a WHOLE different ball of wax.

Yes, you are correct. An employee can normally only change insurance carriers during open enrollment.

There could conceivably be an exception or two. As an example of one exception, suppose Mary has the qualifying event of marriage. After her marriage, she is going to be moving out of state to be with her husband and will be transferring to your office in Boston. Mary is currently covered on Oxford, which does not cover the Boston area. In that case, you would be able not only to let her add her new husband to the plan, but also to change from Oxford to Blue Cross Blue Shield.

But for the most part, a qualifying event only allows an employee to make changes to their CURRENT plan.

I'm sure the reason you got differing answers is due to the terminology issue. Dr. Smith is a medical provider. Memorial Hospital is a medical provider. Aetna is an insurance provider.

[Prieta]

That's what most of us thought. Thanks so much for the help!

[cbg]

Any time. That's what we're here for.