Notice of Special Enrollment Rights
If you decline enrollment for yourself or an eligible dependent (including your spouse) while other health insurance or group health plan coverage is in effect, you may be able to enroll yourself and your dependents in the plans offered by [Employer Name] if you or your dependents lose eligibility for that other coverage (or if the employer stops contributing toward your or your dependents’ other coverage). You must request enrollment within 30 [or 31] days after your or your dependents’ other coverage ends (or after the employer stops contributing toward the other coverage).
You may also be able to enroll if you or your dependents lose eligibility for coverage under Medicaid or a state Children’s Health Insurance Plan (CHIP) and request enrollment within 60 days of losing Medicaid or CHIP.
You may also be able to enroll if you or your dependents become eligible for state premium assistance from Medicaid or CHIP towards the cost of the group health plan, and request enrollment within 60 days of eligibility for state premium assistance.
In addition, if you have a new dependent as a result of marriage, birth, adoption, or placement for adoption, you may be able to enroll yourself and your new dependents. You must request enrollment within 30 [or 31] days after the marriage, birth, adoption, or placement for adoption.
If employer requires declination/waiver form (recommended):
If you decline enrollment for yourself or for an eligible dependent, you must complete a waiver form, provided by [Employer Name] to decline coverage. On the waiver form, you are required to state that coverage under another group health plan or other health insurance is the reason for declining enrollment, and you are asked to identify that coverage. If you do not complete the form or do not have other health coverage in effect, you will not have special enrollment rights (unless you have a new dependent as a result of marriage, birth, adoption or placement for adoption.)
To request special enrollment or if you have questions regarding special enrollment rights, please contact the [Employer Name] Human Resources Department.