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Enrollment Rules and Information

Health Benefit Representatives (HBRs)
Enrollment Rules and Information

shp_hbr_enroll.jpgEnrollment 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:

  • New employees
    Must enroll themselves and their dependents within 30 days from their date of hire.

  • Adding/dropping dependents
    Must occur within 30 days from a qualifying life event.

    Do your employees need to update their Primary Care Provider listing in eEnroll? Here's a guide to tell them how!

  • 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.

  • State Health Plan Required Documentation for Qualifying Life Events  & Dependent Eligibility
    Section 125 of the Internal Revenue Code (IRS) provides guidelines for a Qualifying Life Event (QLE) status change. Employees must upload documents into eEnroll or provide supporting documentation to their Health Benefits Representative to verify the qualifying life event in accordance to State Health Plan policy. Employees are also required to provide documentation of a dependent’s eligibility when added to the Plan due to New Hire event, QLE, or Open Enrollment. Click here for the list of supporting documents.
  • Employee terminations
    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 (d) 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​

Eligible Dependents

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. Click here for a brief video that demonstrates how HBRs review submitted documents in eEnroll.

An eligible dependent of a covered employee includes:

  • Legal spouse;

  • 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.

Important Policies

Policy on Member Terminations and Reinstatements
SHP Enrollment Exceptions and Appeals

SHP Policy on Arrears