Help for Qualifying Enrollment Events

A special qualifying event allows members to enroll in or make changes to their benefits during the year outside of Annual Enrollment.

There are two main ways to qualify for an SQE:

Losing coverage may include:

  • Loss of other group health insurance (for any reason).
  • Divorce (losing spouse’s coverage).
  • Death of a spouse.
  • Loss of TennCare, Children's Health Insurance Program or other government coverage.

It's important to note that voluntary loss of coverage (cancelling coverage on purpose, not paying premiums or dropping coverage during another plan's enrollment) does not count as an SQE. 

Acquiring a new dependent can happen in a few ways:

  • Marriage.
  • Birth of a child.
  • Adoption.
  • Placement for adoption.
  • Legal guardianship (court-ordered).

Continue reading for details on qualifying events, application deadlines, required documentation and how coverage effective dates are determined.

How to Submit An Enrollment Request

Use the Enrollment Change Application form and submit enrollment requests directly to Benefits Administration for processing.

Members may also work with their Agency Benefits Coordinator(s) to submit requests on their behalf.

Loss of Eligibility

If an employee or dependent otherwise eligible to enroll declined coverage when it was previously offered during an initial eligibility period or during a subsequent annual enrollment period, and had coverage under any group health plan at the time this plan’s coverage was previously offered, and lost eligibility under another group insurance plan for any reason (including divorce, death of spouse, involuntary loss of other government coverage), then:

  • When an employee satisfies the above requirements, the employee and all dependents of the employee are eligible for special enrollment. 
  • When a dependent satisfies all the above requirements, only that dependent, the employee and other dependents who satisfy the requirements above are eligible for special enrollment.
  • Individuals who lose other coverage may only enroll in the types of coverage lost (medical/medical; dental/dental; vision/vision). A voluntary action that results in loss of coverage is not a qualifying event, including a voluntary cancellation of coverage, a cancellation of coverage for not paying premiums or electing to cancel, waive or decline coverage during another plan’s enrollment period.
  • If adding dependents to existing health insurance coverage, the employee and their dependents may transfer to a different carrier or health care option, if eligible.

Deadline: Application for enrollment with required documentation must be submitted to and received by the ABC/BA within 60 days of the loss of eligibility.

Effective date: First day of the month after a completed application with documentation is received by the ABC/BA.

Documentation required: Written documentation from an employer, former employer, insurance company or former insurance company on company letterhead that lists (1) names of covered participants; (2) dates of coverage including your coverage at the time coverage in this plan was declined; (3) types of coverage (medical, dental, vision); (4) each participant that lost eligibility for coverage; (5) the date of loss of eligibility to continue coverage and (6) the reason why eligibility for coverage was lost.

Acquisition of New Dependent

This section explains how employees can update their coverage when adding dependents due to marriage, guardianship, birth or adoption. Employees may enroll in employee-only or family coverage and can add newly eligible dependents, including those not previously enrolled, if they remain eligible.

  • The employee may enroll in employee-only or family coverage.
  • The employee may add new dependents and any eligible dependents who were not enrolled when initially eligible and are still eligible.
  • If adding dependents to existing health insurance coverage, you and your dependents may transfer to a different carrier or health care option, if eligible.
  • Head of contract and eligible dependents may enroll in dental and vision coverage if the requirements stated in the dental or vision certificates of coverage are met.

Deadline: Application for enrollment with required documentation* must be received by the ABC or BA within 60 days of the date of acquisition (the date of acquisition is the date of the marriage or the date of the placement order).

Effective date: First day of the month after a completed application with documentation is received by the ABC or BA.

Documentation required:

  1. Marriage Certificate.
  2. Birth Certificate (will accept mother’s copy for newborn).
  3. Order of Guardianship requiring financial support and provision of insurance coverage, which sets out the date of the guardianship period.
  • No employee-only coverage is permitted.
  • All change requests due to an Order of Guardianship must arise out of and correspond with the terms of the guardianship order.
  • HOC and eligible dependents may enroll in dental and vision coverage if the requirements stated in the dental or vision certificates of coverage are met.

Deadline: Application for enrollment with required documentation* must be received by the ABC or BA within 60 days of the date of acquisition (the date of acquisition is the date of the marriage or the date of the placement order).

Effective date: First day of the month after a completed application with documentation is received by the ABC or BA.

Documentation required:

  1. Marriage Certificate.
  2. Birth Certificate (will accept mother’s copy for newborn).
  3. Order of Guardianship requiring financial support and provision of insurance coverage, which sets out the date of the guardianship period.
  • Enrollment should be completed and submitted to the ABC or BA within 30 days to ensure the earliest possible effective date.
  • The employee may enroll in employee-only or family coverage.
  • The employee may add new dependents and any other eligible dependents who were not enrolled when initially eligible and are otherwise still eligible.
  • If dependents are added to existing health insurance coverage, HOC and eligible dependents may transfer to a different carrier or health care option, if eligible.
  • HOC and eligible dependents may additionally enroll in dental and vision coverage if the requirements stated in the dental or vision certificates of coverage are met (no retroactive coverage is available for dental and vision).

Deadline: Application for enrollment with required documentation* must be received by the ABC or BA within 30 days of the birth, adoption or placement for adoption for retroactive health insurance coverage (with an effective date of the date of birth, adoption or placement for adoption). Other coverage (dental/vision) will begin the first day of the month following the enrollment request.

An application with required documentation* that is received by the ABC or BA 31 to 60 days after the birth, adoption or placement for adoption will result in an effective date of the first day of the following month.

Documentation required:

  1. Birth Certificate (will accept mother’s copy for newborn).
  2. Final Order of Adoption or Order of Custody in anticipation of adoption.

*Employees have an additional 10 days after the deadline to submit required dependent documentation. 

Deadline and Effective Date Examples

Examples of deadlines and effective dates for new dependents (assuming that all eligibility requirements are met and all required documentation is submitted with the application).

Within 30 days

If enrollment is submitted to BA on June 25 (within 30 days of marriage):

  • All coverage will begin July 1, the first day of the month following submission of the completed application.

31-60 days

If enrollment is submitted to BA on Aug. 14 (60 days after marriage):

  • All coverage will begin Sept. 1, the first day of the month following submission of the completed application.

After 60 days

An enrollment submitted on or after Aug. 15 (61 days after the event) will exceed the 60-day enrollment period, and the request will be denied.

Within 30 days

If enrollment is submitted to BA on June 25 (within 30 days of birth):

  • Health insurance will be retroactive to June 15, the date of birth.
  • All other coverage (dental/vision) will begin July 1, the first day of the month following submission of the completed application.

31-60 days

If enrollment is submitted to BA on July 16 (31 days after birth):

  • All coverage will begin Aug. 1, the first day of the month following submission of the completed application.

If enrollment is submitted to BA on Aug. 14 (60 days after birth):

  • All coverage will begin Sept. 1, the first day of the month following submission of the completed application.

After 60 days

An enrollment submitted on or after Aug. 15 (61 days after the event) will exceed the 60-day enrollment period, and the request will be denied.

New Eligibility for Premium Subsidy

An employee and any dependents newly eligible for a premium subsidy through a CHIP or Medicaid program may enroll in health insurance coverage midyear. The enrollment application with documentation must be received by the ABC or BA within 60 days of the new eligibility.

Dependent Documentation

When adding new dependents to coverage, documentation is required. The full list of required documents can be found on the dependent eligibility, definitions and required documents.