CHIPRA Premium Assistance and CHIP Special Enrollment: What Employers Owe
Federal law gives employees and dependents a 60-day special enrollment right tied to Medicaid and CHIP, and it requires employers in states with premium assistance programs to send a written notice. Here is what the statute says and what to check in your plan.
Four Pages On One Federal Right.
General information, not legal or tax advice.
The 60-Day CHIP Special Enrollment Window
The two events that start the clock, who can use the right and what the statute leaves unsaid.
The Employer CHIP Premium Assistance Notice
Who must send the notice, how it can travel with enrollment materials and the penalty in the statute.
How CHIP Premium Assistance Works With Your Group Plan
What the state may pay, what stays voluntary and what a plan administrator may be asked to disclose.
Plan Document and SPD Language for CHIP Special Enrollment
Where the right belongs in your documents, what DOL says about the SPD and what we could not confirm.
Where Things Stand.
Section 701(f)(3) of ERISA, 29 U.S.C. 1181(f)(3), came from the Children’s Health Insurance Program Reauthorization Act (CHIPRA). It requires a group health plan to let an employee who is eligible for coverage but not enrolled sign up in two situations. One is when the employee or a dependent loses Medicaid or CHIP coverage because eligibility ends. The other is when the employee or dependent is found eligible for state premium assistance toward the group plan. In both cases the request is due within 60 days.
The same section has an employer side. An employer that maintains a group health plan in a state that provides Medicaid or CHIP premium assistance must give each employee a written notice about the opportunities then available in the state where the employee lives. DOL says the notice must be provided annually, and it publishes a model notice with state contact information.
Premium assistance itself is a state program, not an employer benefit. Under 42 U.S.C. 1397ee(c)(10) and 42 U.S.C. 1396e-1, a state may pay part of the cost of employer coverage when that is cost-effective, and taking the help is the family’s choice. Your job is to honor the enrollment window, deliver the notice and answer the state if it asks about plan benefits.
What We Check In A Plan Review.
In a review we look at four things. First, whether the plan’s eligibility and special enrollment provisions list the Medicaid and CHIP events next to the other special enrollment events. The statute says the plan shall permit enrollment whether or not the plan document mentions it, so a gap in the document is a risk, not a defense.
Second, whether the annual notice reaches every employee, including those who live in a different state from your office, and whether it uses the current DOL model. Third, who receives a state request for benefit information and how quickly that person can answer. Fourth, whether enrollment staff know that a request tied to these events is counted in days from the state’s action, not from your open enrollment dates.
Two points we could not confirm at a primary source, and we say so rather than guess: the coverage start date the law requires for these special enrollees, and any federal rule on what the SPD must say about the right. Each page in this series flags them where they matter. This series covers federal law only. For any state’s program details, use the state contacts in the DOL model notice.
Related Rules And Tools.
ERISA Part 7 Group Health Plan Requirements Checklist
The wider set of federal rules that govern group health plan design and notices.
A Compliance Calendar for Your Plan Year
A plan-year view of the dates that matter, including the annual notice.
Selecting and Monitoring Health Plan Service Providers
How to oversee the administrators and vendors who handle enrollment and notices.
Laws And Sources
ERISA Section 701(f), 29 U.S.C. 1181: The statute text for the CHIP special enrollment right in paragraph (f)(3), the employer notice duty and the plan administrator disclosure to states.
ERISA Section 502(c)(9), 29 U.S.C. 1132: The civil penalty of up to $100 a day for an employer that fails the CHIP notice duty.
Social Security Act Section 2105(c)(10), 42 U.S.C. 1397ee: The CHIP state option to pay a premium assistance subsidy for employer-sponsored coverage.
Social Security Act Section 1906, 42 U.S.C. 1396e-1: The Medicaid option to pay premiums for employer group health plans.
29 CFR 2590.701-6: The special enrollment regulation. The text we reviewed covers loss of other coverage and new dependents and does not mention Medicaid or CHIP.
DOL EBSA, CHIPRA: The Department of Labor page for the Children’s Health Insurance Program Reauthorization Act and its employer topics.
DOL EBSA Fact Sheet, HIPAA Special Enrollment and CHIPRA: DOL’s summary of the two special enrollment events, the 60-day request period and the employer notice.
DOL Health Coverage Portability (HIPAA) Compliance FAQs: DOL answers on the Employer CHIP Notice, the annual requirement, the model notice and the SPD.
Federal Register, February 4, 2010, Model Notice for Employers: DOL and HHS publication of the model employer notice, with the first deadlines and delivery rules.
DOL EBSA, CHIP Model Notice for Employers: The DOL docket page for the 2010 model notice, with links to the English and Spanish model notice files.
General information, not legal or tax advice.
Quick Answers.
Brief answers to what employers ask about CHIP premium assistance and special enrollment.
How long does an employee have to ask for coverage after losing Medicaid or CHIP?
Sixty days. Under ERISA section 701(f)(3)(A)(i), 29 U.S.C. 1181(f)(3)(A)(i), an eligible employee who is not enrolled must request coverage not later than 60 days after the date coverage under Medicaid or CHIP ends because of loss of eligibility.
Who has to send the employer CHIP notice, and how often?
The employer. Under 29 U.S.C. 1181(f)(3)(B)(i)(I), an employer that maintains a group health plan in a state with a Medicaid premium assistance program must give each employee a written notice. DOL says it must be provided annually and may go out with the SPD, enrollment packets or open season materials.
Does the state pay our plan directly?
It can. The CHIP statute, 42 U.S.C. 1397ee(c)(10), lets a state pay a premium assistance subsidy, and it lets an employer notify the state that it elects not to be paid directly. Participation is voluntary for the family.
What is the penalty if we skip the notice?
ERISA section 502(c)(9), 29 U.S.C. 1132(c)(9), lets the Secretary of Labor assess a civil penalty of up to $100 a day against an employer that fails the notice duty, and each violation involving one employee counts separately. We have not verified the current inflation-adjusted amount.
Does our summary plan description have to mention CHIP special enrollment?
We found no CHIP-specific SPD content rule at a primary source. DOL says the employer notice may be delivered with the SPD, and 29 CFR 2590.701-6(c) covers notice of special enrollment rights generally. We recommend listing the Medicaid and CHIP events.
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