Wisconsin Health Insurance Enrollment Periods and Portability

Special Enrollment Periods

Certain individuals who waive coverage when first eligible under a group health benefit plan may later decide to enroll under the plan and not be considered "late enrollees." A special enrollment period is triggered when an eligible employee obtains a new dependent through marriage, birth, adoption, or placement for adoption. If an eligible employee, spouse and/or dependent apply for coverage under a group health benefit plan within 30 days of a marriage, birth, adoption, or placement for adoption, they may not be treated as "late enrollees."

A special enrollment period is also triggered when an eligible employee or dependent who previously waived coverage under a group health benefit plan, because the individual was covered under other health insurance, later loses that other coverage. The individual must request special enrollment within 30 days after the date on which the other coverage is exhausted or terminated. In addition, Wisconsin insurance laws allow an individual who previously waived coverage under a group health benefit plan because the individual was covered under other health insurance coverage, to later enroll in the plan while the individual is currently covered under the other coverage.

What is Portability?

Portability is designed to keep an individual from having to meet a new preexisting condition waiting period when enrolling in an employer-sponsored group health benefit plan. In situations where an individual changes jobs or has had continuous health insurance or other "creditable coverage" prior to enrolling in an employer-sponsored group health benefit plan, any preexisting condition waiting period under the new group health benefit plan must be reduced by the period of time an individual had prior "creditable coverage" provided there is not a break in coverage longer than 62 days. An employer imposed probationary period before an employee is eligible to enroll for coverage does not count towards a break in coverage. Portability applies to both fully-insured group health benefit plans and to employers' self-insured plans.

Portability does not apply when an individual enrolls for coverage under an individual health plan or a nonemployer-sponsored group health plan, except in certain cases when an individual applies for coverage under the state Health Insurance Risk- Sharing Plan (HIRSP). The plan's 6-month preexisting condition waiting period will be waived for an eligible individual who has at least 18 months of prior creditable coverage, the most recent coverage under an employer's group health plan, governmental plan, or church plan. In addition, the most recent group coverage cannot have been terminated for any reason relating to fraud or a failure to pay premiums, the individual must have elected and exhausted any continuation rights under the prior group plan, and the individual cannot have other creditable coverage or be eligible for coverage under an employer group health plan, Medicare, or Medicaid.