W. Va. Code R. § 114-54-8

Current through Register Vol. XLI, No. 50, December 13, 2024

Section 114-54-8 - Special Enrollment Periods

8.1. A health insurer shall permit individuals to enroll for coverage under terms of a health benefit plan, without regard to other enrollment dates permitted under the group health plan, if an eligible employee requests enrollment for himself or herself or, if the group health plan makes coverage available to dependents, on behalf of a dependent who is eligible but not enrolled under the group health plan, during the special enrollment period, which shall be (30) thirty days following an event described in subsections 8.2 or 8.3 with respect to the individual for whom enrollment is requested. A health insurer may impose enrollment requirements that are otherwise applicable under terms of the group health plan to individuals requesting immediate enrollment.

8.2. An individual, who previously had other coverage for medical care and for whom an eligible employee declined coverage under the group health plan, may be enrolled during a special enrollment period if the individual has lost the other coverage for medical care and:

a. If required by the group health plan, the eligible employee stated in writing when declining the coverage, after being given a notice of the requirement for, and the consequences of failure to submit, a written statement, that coverage was declined because the individual had coverage for medical care under another group health plan or otherwise; and

b. When enrollment was declined for the individual:

1. The individual had coverage under a COBRA continuation provision, as defined in W. Va. Code '33-15-2a(c), and the coverage has been exhausted; or

2. The individual had coverage other than under a COBRA continuation provision and the coverage has been terminated due to loss of eligibility for the coverage, including loss of coverage as a result of legal separation, divorce, death, termination of employment, reduction in the number of hours of employment and any loss of eligibility after a period that is measured by reference to any of the foregoing, or termination of employer contributions towards the other coverage. For purposes of this paragraph:

A. Loss of eligibility for the coverage does not include loss of eligibility due to the eligible employee's or dependent's failure to make timely premium payments or termination of coverage for cause such as making a fraudulent claim or intentional misrepresentation of material fact in connection with the group health plan; and

B. Employer contributions include contributions by any current or former employer of the individual or another person that was contributing to coverage for the individual.

8.3. If the eligible employee has previously declined enrollment under the group health plan but acquires a dependent through marriage, birth, adoption or placement for adoption, the eligible employee or dependent may be enrolled during the special enrollment period with respect to the individual.

8.4. Enrollment of the eligible employee or dependent is effective not later than the first day of the calendar month beginning after a completed request for enrollment is received or, for a newborn or adopted child, on the date of birth, adoption or placement for adoption.

W. Va. Code R. § 114-54-8