Loss of Other Employer-Sponsored Group Coverage

An employee and their dependents, and non-active subscriber's dependents, may enroll within 60 days if they involuntarily lose employer-sponsored coverage for one of the following reasons:

• Medical, dental, or vision plan terminates
• Eligibility for coverage ends
• Employer contributions toward the plan end
• COBRA coverage ends

If a Public Entity offers more than 1 medical plan, medical plans may be changed when adding dependents due to a loss of employee-sponsored group coverage. If changing medical plans, any amounts paid toward the deductible and out-of-pocket maximum will transfer to the new plan.

Submit completed enrollment form indicating the coverage loss reason and date in the Other Reason field, a letter from former employer stating reason for coverage loss, and proof of prior group coverage within 60 days of date of lost coverage. Coverage becomes effective the first of the month after receipt of form. If the form is received on the first day of the month, coverage is effective that same day. Enrollment is not complete until all required documentation is received.

Active subscribers who fail to enroll during the 60-day period may enroll during the next Open Enrollment for coverage effective the following January.

Retiree subscribers must submit proof the dependent was covered for 12 months immediately prior to loss of coverage. Retirees who fail to enroll eligible dependents during the 60-day period cannot enroll them at a later date.