HIPAA Special Enrollment Rights (SERs) are federally required opportunities that allow employees and dependents to enroll in – or make certain changes to – a group health plan outside of Open Enrollment, as long as the individual is still eligible for the employer’s plan. These same SERs also exist under the ACA for Individual and Family Plans on the state Exchanges, offering parallel protections when someone loses coverage or experiences a qualifying life change.
SERs exist so families aren’t left without coverage when major life events occur. And while many employers casually refer to these moments as “HIPAA QEs,” that’s not technically correct – under HIPAA, they’re Special Enrollment Rights, distinct from:
- IRS Section 125 qualifying events (pre-tax election changes), and
- COBRA qualifying events (loss-of-eligibility events).
SERs apply to virtually all group health plans, including major medical, dental, vision, and other group benefits when they meet the definition of a group health plan.
Refer to our Qualifying Events (QEs) & Special Enrollment Rights WB Compliance Wiki page for more general information on these items.
When HIPAA SERs Apply
A HIPAA Special Enrollment Right exists when all of the following are true:
- The employee or affected dependent is still eligible for the employer’s group health plan,
- A HIPAA-defined event occurs, and
- The employee requests enrollment or makes a plan change within the required timeframe.
A HIPAA SER doesn’t just allow someone who previously waived coverage to enroll – it also permits an already-enrolled employee to change plans when the event affects coverage needs (for example, marriage, birth, or a dependent losing their own coverage).
These rights preserve access to coverage. They do not allow reinstatement into a plan that terminated someone due to loss of eligibility, but they do guarantee the right to enroll in any plan the employee is eligible for at the time of the SER.
HIPAA SER: Loss of Other Coverage
This is one of the most common HIPAA SERs. When an employee or dependent loses other minimum essential coverage, they gain the right to enroll in an available employer plan outside Open Enrollment.
Loss of coverage includes:
- Loss of employer-sponsored coverage (their own or a spouse’s/parent’s)
- Loss of individual or Marketplace coverage
- Loss of Medicaid or CHIP
- Coverage ending due to divorce, legal separation, or death
- Loss of coverage because another employer stops contributing
- Exhaustion of COBRA
What this SER allows
- Enroll in any employer plan they’re eligible for
- Add affected dependents
- Change plans if options are available
- Or enroll in an Individual & Family Plan on a state Exchange
What this SER does not allow
- Reinstatement into the exact plan that terminated their coverage. HIPAA ensures continued access to coverage – not re-entry into a plan that ended due to loss of eligibility.
HIPAA SER: Gaining a New Dependent
These SERs allow employees to add dependents – and make plan changes for themselves – even if they previously waived coverage.
Events include:
- Marriage
- Birth
- Coverage for a newborn must be available retroactively to the date of birth
- Adoption or placement for adoption
- Also retroactive to the placement date
HIPAA overrides previous waivers or declinations – these events always reopen enrollment.
HIPAA SER: Medicaid/CHIP Eligibility Changes
A HIPAA SER applies when an employee or dependent:
- Becomes newly eligible for Medicaid or CHIP premium assistance, or
- Loses Medicaid/CHIP eligibility entirely
This is one of the few SERs with a longer window: 60 days instead of the usual 30.
HIPAA SER: Loss of Coverage Due to Moving Out of a Service Area
This is common with HMOs or narrow networks.
If a covered individual moves outside the plan’s service area and loses access to care, HIPAA requires the employer to offer a Special Enrollment Right into another available employer plan (or the individual may enroll through a state Exchange).
Employer Responsibilities
Employers must:
- Honor SER Requests
- HIPAA requires employers to process eligible SERs even if the employee previously declined coverage.
- Follow the Required Timeframes
- Most HIPAA SERs: 30 days
- Medicaid/CHIP SERs: 60 days
- Plan documents must clearly state these deadlines.
- Provide the HIPAA Special Enrollment Notice
- Every employer offering a group health plan must give employees a written notice describing their HIPAA Special Enrollment Rights, as required by HIPAA and ERISA.
- This is usually included in:
- New hire packets
- ERISA plan documents, SPDs, Wraps
- Open Enrollment materials
- The notice informs employees of their right to enroll when they lose other coverage or gain a dependent.
- Apply Rules Consistently
- HIPAA is mandatory – employers cannot “opt out,” shorten timeframes, or create additional requirements. HIPAA law applies to employer health plans of all sizes. There is no small-employer exemption.
- Document and distribute HIPAA Portability and Special Enrollment Rights practices in required ERISA plan documentation.
Documentation Employers May Request
Employer plan administrators may request reasonable proof of the SER, such as:
- Termination letter
- Marriage certificate
- Birth certificate or hospital birth confirmation
- Adoption or placement papers
- Medicaid/CHIP eligibility or determination notice
Documentation helps verify the timing, because SERs are time-sensitive.
Timing Rules (Summary)
Employees must request enrollment:
- Within 30 days for most HIPAA SERs
- Within 60 days for Medicaid/CHIP SERs
Coverage generally begins the first of the month following the enrollment request – except birth/adoption, which may require retroactive coverage back to the date of birth. Check the terms of the health plan and ERISA documentation for more information.
Why HIPAA SERs Matter
HIPAA SERs are the safety net that keeps families covered during major life changes – without waiting for Open Enrollment. They protect employees from accidental gaps in coverage and allow families to enroll or switch plans when:
- A baby arrives
- A spouse loses other coverage
- Someone moves out of a service area
- Medicaid/CHIP eligibility changes
These rights ensure access to coverage exactly when people need it most – and have been federal law since 1996.