Professional Musicians, Local 47 and Employers’ Health & Welfare Fund:

Have You Lost Coverage Under an Employer Provided Group Health Plan Other Than the Local 47 Health & Welfare Fund?

Special Enrollment Rights

Federal law – namely the Health Insurance Portability and Accountability Act (HIPAA) — requires the Fund to permit individuals who declined health coverage under the plan, because they had other group health plan or health insurance coverage, to enroll in the plan through special enrollment upon any loss of eligibility for the other coverage or if employer contributions toward the other coverage cease.

Under HIPAA, individuals who are otherwise eligible, but had declined health coverage because they had other group health plan or health insurance coverage, must be permitted to enroll in the plan (regardless of any late enrollment provisions) upon loss of eligibility for the other coverage or if employer contributions toward the other coverage cease.

Loss of eligibility includes loss of coverage due to legal separation, divorce, voluntary or involuntary termination of employment, reduction in hours, children’s aging out of coverage (now age 26 pursuant to the Affordable Care Act), or moving out of an HMO’s service area. It does not include loss of coverage due to a failure of the individual to pay his/her own premiums on a timely basis or termination of coverage for cause.
Under HIPAA, special enrollment rights are also triggered when employer contributions toward an individual’s other coverage cease, regardless of whether the individual is still eligible for coverage under the other plan.

If you obtained eligibility through the Professional Musicians, Local 47 and Employers’ Health and Welfare Fund (the “Fund”) for benefit enrollment and coverage for calendar year 2016 and declined that coverage because you had other group health coverage (i.e., you and/or your dependents were covered under your spouse’s employer provided group health insurance or even if you are directly covered through another employer provided group plan, etc.), and now you’ve or your dependents have lost eligibility for that other group coverage, you may enroll in Fund’s benefit plan if the following conditions are met:

1. The Fund verifies that you were originally eligible for coverage, based on the Fund’s eligibility rules, in one of the benefit levels sponsored by the Fund, during the 2016 calendar year;

2. You submit a completed enrollment form along with the applicable co-premium to the Fund within 30 days of the loss eligibility of your other group coverage; and

3. You provide the Fund with an appropriate Certificate of Creditable Coverage form (see below) – which the plan in which you have lost coverage must provide to you upon your request — with your completed enrollment form and the applicable co-premium payment within 30 day of loss of coverage.
How Do I Know if I’m Eligible for Coverage Through the Fund?

If you have recently lost other group coverage, or are about to lose coverage, and believe that you are eligible for benefits through the Fund, call the Fund office at (818) 243-0222. A Fund representative will advise you of your eligibility status and if you qualify to enroll in one of the levels of benefit plans sponsored by the Fund and which benefit level you have qualified for based on employer contributions made during the 2014-2105 qualification cycle. If you qualify for coverage, you may ask the representative for an enrollment packet, which will contain the available plan level options, premium costs and an enrollment form(s). In any event, you must still meet the three (3) conditions outlined above in order to have a HIPAA enrollment right with the Fund.
What is the Certificate of Creditable Coverage?

The Certificate of Creditable Coverage (the “Certificate”) is a document that shows your prior periods of coverage in another group health plan (which may be sponsored by another employer for whom you or your spouse work; (i.e., a PPO, a POS, an HMO, or other group health insurance). You are entitled to request and receive a Certificate – from the other plan’s administrator — in the following situations:

Before you lose your present coverage: If you know you will be leaving your job, you may request a Certificate, free of charge from the administrator of the other group health plan. The Certificate must be provided to you upon request.

After coverage ends: The administrator of your or your spouse’s employer-provided group plan must send you a Certificate automatically upon loss of coverage, even if you are also eligible for COBRA continuation coverage. If you don’t get one, or if you need a new one, you can request a certificate, free of charge, up to 24 months after the prior coverage ends.

When COBRA coverage ends: You should also automatically receive a Certificate when COBRA continuation coverage ends.
Under current law, the Affordable Care Act, all group medical plans will be required to cover pre-existing conditions, irrespective of prior coverage or the existence of a Certificate. As pointed out above, any request for a Certificate needs to be directed, in writing, to the plan’s administrator.
This article focuses on one aspect of HIPAA special enrollment and is not intended to cover all aspects of HIPAA’s special enrollment rules.