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Cal Poly Pomona

When a Family Member Loses Health Benefits Eligibility

Picture of a man reading information on a computer screen.

When changes take place in your life - such as death of a family member, change in marital status,change in registered domestic partner status, employment, or other circumstances - they can affect health coverage eligibility for you, your spouse or domestic partner, or their dependents.

If an enrolled family member loses eligibility during the year, you are responsible for de-enrolling that family member. Don't wait until Open Enrollment.

What are the consequences of failing to provide information on changes in enrollment in a timely manner? Employees who fail to report changes in their health enrollments in a timely manner could be liable to reimburse for premiums paid in excess of six months from the date the change was recorded. In addition, members may be liable to the health plans for costs incurred as a result of services provided to an ineligible dependent.

If you do not record a deletion or cancellation in a timely manner, you will not be entitled to retroactive benefit premiums beyond six months from the date the cancellation is processed and recorded.

When Do Family Members Lose Eligibility?

Family members lose eligiblity for the following reasons:

Family Member
When Eligibility for Coverage Ends and Documentation Required
Spouse or Domestic Partner
  • When you divorce or dissolve a domestic partnership, your former spouse or domestic partner is no longer eligible to receive health benefits under your coverage. The coverage terminates on the last day of the month in which the final divorce decree or termination of registered domestic partnership is granted. A copy of the final Divorce Decree or Termination of Domestic Partnership is required when you delete a former spouse or domestic partner from your health benefits.
  • Death of a spouse or domestic partner must be reported to Benefit Services as soon as possible.
Children
  • Eligibility for coverage stops on the last day of the month in which your enrolled child attains 23 or marries.
  • Death of an enrolled child must be reported to Benefit Services as soon as possible.

For your spouse/domestic partner, eligibility stops on the last day of the month in which a divorce, legal separation, termination of domestic parnership, or annulment is final.

Generally, COBRA provides that virtually all employers who sponsor group health plans must permit
covered individuals who lose coverage under the plan(s) as a result of certain “qualifying events” set
forth in COBRA to elect to continue their coverage under the plan(s) for a prescribed period of time
on a selfpay
The following three elements are necessary to trigger COBRA eligibility:
1. The individual must be a “qualified beneficiary” (see Section 1.3);
2. The individual must experience a “qualifying event” (see Section 1.4); and
3. The individual must lose group coverage as a result of that qualifying event, within a certain
Qualified beneficiaries are eligible to continue health, dental and vision coverage for up to 18, 29 or
36 months, depending on the qualifying event. Employees enrolled in the Health Care
Reimbursement Account (HCRA) plan may continue participation only until the end of the plan year,
if certain criteria are met (see Section 2).

Retroactivity - Not Making Timely Health Care Changes

When changes take place in your life - such as death of a family member, change in marital status,change in registered domestic partner status, employment, or other circumstances - they can affect health coverage eligibility for you, your spouse or domestic partner, or their dependents. If enrollment changes like this are not reported to Benefit Services in a timely manner, health premiums may be underpaid or overpaid until we are notified.

What are the consequences of failing to provide information on changes in enrollment in a timely manner? Employees who fail to report changes in their health enrollments in a timely manner could be liable to reimburse for premiums paid in excess of six months from the date the change was recorded. In addition, members may be liable to the health plans for costs incurred as a result of services provided to an ineligible dependent.

If you do not record a deletion or cancellation in a timely manner, you will not be entitled to retroactive benefit premiums beyond six months from the date the cancellation is processed and recorded, nor will Cal Poly Pomona--everyone loses!