Enrollment and termination rules are governed by North Carolina General Statute 135 Article B.
Enrollment rules protect members and
provide consistency in administering the State Health Plan. Members
should have timely access to the care they need.
Enrollment inconsistency and
terminations lead to retroactive premium adjustments, reconciliation
issues and claims paid for members who are no longer eligible. HBRs are
asked to review and understand these rules:
Must enroll themselves and their dependents within 30 days from their date of hire.
Must occur within 30 days from a qualifying life event.
Flexible Benefit Plan (Section 125) Rejection Form
Learn how to opt out of the Flexible Benefit Plan, IRS Section 125 and view a list of qualifying life events. Click here for details.
Qualified Life Event Supporting Documentation
Section 125 of the Internal Revenue Code (IRS) provides guidelines for a Qualifying Life Events (QLE) change. Employees must provide supporting documentation to verify the qualifying life event in accordance with the State Health Plan policy. Click here for the list of supporting documents.
Terminations of health coverage must be processed within 30 days. Groups will be responsible for paying the premiums for members who were not terminated in a timely manner.
Please note: The rules for the termination of health coverage due to an employee's end of employment as established by 135-48.44 is as follows:
- 135-48.44 (a) (2) The last day of the month in which an employee's employment with the State is terminated as provided in subsection (c) of this section.
- 135-48.44 (d) (4) If employment is terminated in the second half of a calendar month and the covered individual has made the required contribution for any coverage in the following month, that coverage will be continued to the end of the calendar month following the month in which employment was terminated. This has been determined by legal to be terminations that occur on and after the 16th of the month.
- State agencies (people who enroll through BEACON) follow 135-48.44 (d) (4).
- Public schools, community colleges, local government units, charter schools and other non-BEACON groups basically can make the determination on which rule they wish to follow, but they need to make a decision that will be the standard they follow.
Employees who are paid less than 12 months and summer months:
- 135-48.44 (d) (4) Employees paid for less than 12 months in a year, who are terminated at the end of the work year and who have made contributions for the non-work months, will continue to be covered to the end of the period for which they have made contributions, with the understanding that if they are not employed by another State covered employer under this Plan at the beginning of the next work year, the employee will refund to the ex-employer the amount of the employer's cost paid for them during the non-paycheck months.
What Members Can Do During Open Enrollment
During Open Enrollment, members can:
Enroll in the State Health Plan
Disenroll from the State Health Plan
Switch between plans
Add or remove dependents without a qualifying life event
There will be no exceptions to this rule.
Please remember, when employees enroll they are encouraged to print the
confirmation page upon completion of enrollment. This rule emphasizes
the importance of new hires enrolling in a timely manner and the
consequences that will follow with failure to elect coverage within 30
days (possible gap in coverage, unable to enroll in the Plan until the
next Open Enrollment period, etc.).
Changes reflected in this bill were effective
as of July 1, 2012. The bill revises several sections of General
Statute § 135-48. To view the full text of House Bill 1085, click here.
Please remember that when employees add dependents to their benefit plan, they are asked to provide documentation of dependent eligibility under the State Health Plan.
Dependent Verification Requirements
An eligible dependent of a covered employee includes:
Children up to age 26, including
natural, legally adopted, foster children, children for which the
employee has legal guardianship and stepchildren of the employee.
This includes coverage for such children
(described above) who are covered by the Plan when they turn age 26 to
the extent that they are physically or mentally incapacitated on the
date that they turn age 26. A child is physically or mentally
incapacitated if they are incapable of earning a living due to a mental
or physical condition. Coverage continues for such children as long as
the incapacity exists or the date coverage would otherwise end,
whichever is earlier.
SHP Enrollment Exceptions and Appeals
SHP Policy on Arrears