Major transitions — joyful and somber alike — require corresponding changes to your health insurance. Whether you have a group or individual policy, here's an overview of how to make sure your insurance keeps pace with your life.
Group plans
Are you a member of a group plan? That's good news. Although group health plans require most changes be made during a designated open enrollment period , federal law requires exceptions for major events. This "exception window" is called a special enrollment period .
You can take advantage of special enrollment if you request a change in writing within 30 days of that significant life event, whether it is marriage, birth, adoption, divorce or death.
In addition to changes in your family situation, this special enrollment period must be open if you lose coverage from another source, such as if a spouse loses a job, and need to opt in to a plan you had been offered in the past but chose not to join.
Getting Married
If you have a group health plan, you can most likely enroll your new spouse or vice versa. But if your husband or wife had a policy before the wedding, don't assume that consolidating your health insurance will be cost-effective. Depending on how much each employer contributes to your premium payments and quality of coverage, it may be less expensive to stay on separate plans.
Also, consider your medical needs and preferences, such as doctor choice and whether you regularly require medication that has a lower co-pay under one plan or the other.
Expanding your family
If you are thinking about adding a child to your family, whether through birth or adoption, now is a good time to review your health insurance. Even the healthiest children make their share of visits to the pediatrician.
It is almost always more cost-effective to have the whole family covered under a single plan. If you are already covered under your spouse's or partner's health plan, see what kind of prenatal and pediatric care it covers. If you don't like what you see, see whether you can supplement your existing policy.
If you and your spouse or partner have different plans, compare which plan has better maternal and child coverage and pick one for you all to join. If you have strong feelings about whether you want to give birth in an alternative setting, such as a birth center, or in a particular hospital, make sure your plan allows for that. Also be sure your doctor is in the plan and that you feel comfortable with the choice of pediatricians in your plan's network.
If you wish to add your child to your current insurance, call to let them know when your child is scheduled to arrive and should be covered under your plan. Generally, insurers consider the child covered at birth and will pay for the maternity stay even if the parents have not officially given notice beforehand, but it is always better to let them know. It's also a good idea to double check that the child is on the plan and the other necessary changes have been made after the birth or adoption, even if you called and spoke with someone weeks before. Naturally, if you forgot to make the call before the baby was born, you have to do so afterward. In either case there will be paperwork. If you don't get it within a month after you let the insurer know about the baby, be sure to call and ask for it.
For newborn or newly adopted children there's an additional reason to make sure you sign up for coverage with the 30 days. Insurers can't exclude the child from coverage for having a pre-existing medical condition, even if the condition is known at or before birth, if the child is enrolled in the plan within that time frame.
When your teen hits 19
Most health plans consider children dependent and therefore eligible for coverage under family or group coverage rates until they reach a certain age, typically 19. That happens whether or not you are supporting your children financially or they are living at home.
In some states, children can also be considered dependents for insurance purposes for longer if they have a mental or physical disability or are in the U.S. Armed Forces.
Some plans may provide an extension of the age limit for children who are enrolled in school full-time. This is not indefinite, however. Children in school will eventually become too old to qualify as dependents. Plans may also discontinue coverage of a child through a parent, regardless of age, if the child gets married. If the insurance for a child who ages out is provided by a large employer, the child is likely eligible for COBRA coverage.
Growing concern about the number of uninsured Americans between the ages of 19 and 34 has prompted many state legislatures to look at lengthening the time a child can be considered dependent for insurance purposes. For a look at what your state is doing check the website of the National Conference of State Legislatures.
Death, divorce, separation
At the most emotionally trying points in your life, dealing with your health insurance is probably not topmost in your mind. Nonetheless, it is worth focusing on, however briefly. If you had insurance before the death, divorce or legal separation, you may have certain rights to coverage. Other laws may help make your dependent child remains insured.
If your insurance is through the employer of a deceased spouse or a spouse you are divorcing, that employer may be required to let you and your dependent children continue coverage through COBRA at the group rate for as long at 36 months. If you are eligible, you have 60 days from the date of death, divorce or legal separation to seek COBRA coverage. The law also allows you and your dependents to remain eligible for COBRA even if your spouse canceled your coverage in anticipation of divorce or separation.
The exception to all COBRA rules is small businesses. If your insurance came through a business that employed fewer than 20 people in that calendar year, the business is not required to offer you COBRA coverage.
If you have children and are going through a divorce, you may also be able to obtain a court order known as a Qualified Medical Child Support Order requiring your former spouse's insurer to continue covering them. These orders are handed down through the judicial system on a case-by-case basis during divorce, separation and custody proceedings.
Individual plans
If you want to make changes to an individual insurance policy, it's likely you will have to apply all over again. Unfortunately, there's no guarantee the plan will accept you again. Plus, if you were younger and healthier the last time you enrolled, your premiums may be higher now.
But each insurance company handles family changes differently. A plan may allow you to cover your new baby at the family rate without requiring you to reapply. But if you get married, you might need to submit an application for your new spouse.
Check with your insurance company before you apply for coverage or when you think you might have a change in your family that would require a change in coverage.
