1. Can I change from one plan to another during the year?
Yes, but only if you, the subscriber, file a health benefits application within 30 days for the following events with coverage effective on the first day of the month on or following receipt of the application:
- Move from your plan's service area (for example, out of the county) for a period of at least three months. Your new coverage will be effective subsequent to your move. You may again change plans when you return for three months by submitting another application within 30 days before or after your return. (See Question below: What if I have a temporary or permanent move from the service area?)
- You involuntarily lose eligibility for other coverage or lose the employer contribution for it. The expiration of COBRA permits you to enroll but if you lose COBRA due to non-payment of premium, that does not permit you to enroll.
- You add one or more dependents due to marriage.
- You add one or more dependents due to birth, adoption, or placement for adoption. You have 60 days to make the change under this event.
- Retirees and Survivors only: If you or a dependent newly enroll in Medicare Parts A and/or B, you may change health plans. You should submit your application to ETF prior to your Medicare effective date, and it can be sent up to 3 months in advance of the change. This will mean that your new plan will be effective at the same time as Medicare.
You may also submit the application up to 30 days after your Medicare effective date, but if you do, effective January 1, 2024, you will not be able to have the new plan effective with your Medicare start date. If submitted within 30 days after Medicare's effective date, your new plan will begin the first of the month following receipt by ETF.
See the Life Events Guide for more information.
Note: If your premiums are being deducted post-tax, you may cancel coverage anytime. If your premiums are being deducted on a pre-tax basis, you may cancel coverage mid-year only if you become eligible for and enroll in other group coverage (not for example, Medicare) or terminate employment.
Otherwise, you can only change health plans without restriction during each annual open enrollment period and coverage will be effective the following January 1.
2. If I change plans, what happens to any out-of-pocket maximums that may apply to services I've received?
When you change health plans for any reason (for example, during an open enrollment period or for a move from a health plan's service area), any annual health insurance out-of-pocket maximums under Uniform Benefits (such as durable medical equipment) will start over at $0 with your new plan, even if you change plans mid-year, with the exception of the prescription annual out-of-pocket maximum. If you are enrolled in the Uniform Dental Benefit, you will continue accumulating to the same benefit maximums as well.
If you do not change health plans but move between two options offered by the same health plan mid-year, your benefit maximums and out-of-pocket limits will continue to accumulate. For example, changing from individual to family coverage, or if you or your spouse change to become the subscriber.
3. What if I have a temporary or permanent move from the service area?
If you move out of a service area (for example, out of the county), either permanently or temporarily for 3 months or more, you will be permitted to enroll in the Local Access Plan or an available Local Health Plan that offers in-network providers near you, provided an application for such plan is submitted within 30 days before or after relocation. You will be required to document the fact that your application is being submitted due to a change of residence.
If your relocation is temporary, but for longer than three months, you may again change plans by submitting an application within 30 days before or after your return.
You must submit your application to change coverage as soon as possible and no later than 30 days after the change of residence to maintain coverage for non-emergency services. The change in plans will be effective on the first day of the month on or after your application is received by your employer (by ETF for retirees), but not prior to the date of your move. If your application is received after the 30-day deadline, you will not be allowed to change plans until the following open enrollment period or in certain situations. See Enrolling for Coverage FAQs Question: Are there other enrollment opportunities available to me after my initial one expires?
4. What if I change plans but am hospitalized before the date the new coverage becomes effective and am confined as an inpatient on the date the change occurs (such as January 1)?
If you are confined as an inpatient (in a hospital, a skilled nursing facility, or in some cases, an Alcohol and Other Drug Abuse (AODA) residential center, or require 24-hour home care on the effective date of coverage with the new plan, you will begin to receive benefits from your new plan unless the facility you are confined in is not in your new plan's network. If you are confined in such a facility, your claims will continue to be processed by your prior plan as provided by contract until that confinement ends and you are discharged from the non-network hospital or other facility, or 12 months have passed. If you are transferred or discharged to another facility for continued treatment of the same or related condition, it is considered one confinement.
In all other instances, the new plan assumes liability immediately on the effective date of your coverage, such as January 1.
5. What if I have an adult child who is disabled and I am changing health plans during open enrollment?
Each health plan is responsible for determining whether a newly enrolled disabled dependent continues to meet the contractual definition of a disabled dependent.
(See the Dependent Information FAQ section.)