Run open enrollment and keep a group benefits program operationally compliant: a backward-planned enrollment cycle (timeline, eligibility, QLE/special enrollment, communications, carrier/EDI coordination) and the recurring compliance calendar (COBRA, HIPAA, ACA 1095-C/1094-C, ERISA Form 5500 + SPD/SBC) — educational scaffolding, not legal advice.
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---
name: enrollment-and-compliance
description: "Run open enrollment and keep a group benefits program operationally compliant: a backward-planned enrollment cycle (timeline, eligibility, QLE/special enrollment, communications, carrier/EDI coordination) and the recurring compliance calendar (COBRA, HIPAA, ACA 1095-C/1094-C, ERISA Form 5500 + SPD/SBC) — educational scaffolding, not legal advice."
---
# Enrollment & Compliance
## Enrollment is a deadline-driven project
Backward-plan from the effective date: system build/test, communications, the decision window, processing, and the carrier/EDI cutover each have lead times. A slipped milestone shows up as a coverage gap on day one. Communicate the decision (what fits me), not a 60-page SPD dump — the SPD is the legal record, the comms are the help.
## Eligibility is rules, not vibes
Class definitions, waiting periods, hours/ACA measurement, dependent rules, and the qualifying-life-event / special-enrollment windows are precise. Write them down — ambiguity here becomes a claim dispute later.
## Continuation & privacy
COBRA qualifying events, notice timing, and election windows are exact; HIPAA covers special enrollment and privacy basics. A missed COBRA notice is real liability — fix the forward process and escalate any past exposure to ERISA counsel rather than paper over it.
## The compliance calendar
A standing calendar beats year-end panic: ACA Forms 1095-C/1094-C (employer reporting, ALE context), ERISA Form 5500 + Summary Annual Report, SPD/SBC distribution, and the recurring notices (Medicare Part D creditable-coverage, CHIP, WHCRA). Each has a trigger, an owner, and a deadline. `[verify-at-build]` the current-year dates and form numbers — they shift.
## Carrier coordination
Reconcile eligibility every cycle, not at audit — EDI/834 drift between the HRIS and the carrier is where people lose coverage silently. The carrier and counsel **confirm** filings and legal interpretation; you coordinate and make sure nothing is missed.
## Output
An enrollment plan and/or a compliance calendar: the backward-planned timeline, the eligibility rules, the QLE handling, the carrier/EDI checklist, and the filing obligations with triggers and timing — flagged as educational with a carrier/ERISA-counsel confirmation step. Route plan-design problems to `benefits-advisor` and the renewal/rate story to `underwriting-and-actuarial-analyst`.
