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How to set, manage, and change an employee's plan eligibility

Companies may offer certain plans only to certain individuals, which requires plan eligibility restrictions in Zenefits. For example, an executive class of employees may be eligible for a richer medical plan or higher life benefit.To identify whether restricting plans is compliant, please consult your broker and insurance carrier.

Additionally, carriers may have plan restrictions (tobacco vs non tobacco, state of residency, etc) that aren't monitored through normal plan settings. 

Note: Carrier plan restrictions most commonly exist for Life and Disability plans.

To restrict plan eligibility, gates need to be created and maintained. Please note that this function restricts eligibility per plan, not per line of coverage. For assistance managing employee eligibility for a line of coverage, you can use this page.

Employees' plan eligibility can be restricted by assigning employees a label (which corresponds to a plan restriction) based on attribute or manually.

  • Existing fields in Zenefits
    • Employment Type
    • State of Residence
    • Work Location
    • Department
    • Annual Salary
    • Compensation Type
  • Custom Fields
  • Manual Assignment

How do I set up plan eligibility for the first time?

Please utilize your support channel to request plan eligibility to be restricted, and include the following details:

  • Company name
  • Line of coverage
  • Plan name(s)
  • Reason (example: Classed plan)
  • Definition (example: Class 1 is Executives)
  • Employee attribute (example: executives are employees with salary greater than $50,000)
  • Full census of employees' eligibility (example: spreadsheet of employees per class)

Maintaining plan eligibility during renewal

Please set Plan Mapping in the Start Renewals tool. If plan eligibility is already set up, the system will roll over the existing restrictions based on Plan Mapping.

Editing plan eligibility at renewal

You can utilize your support channel to request plan eligibility edits. If you request changes, make sure to include the following information.

  • Company name
  • Line of coverage
  • Plan name(s)
  • Changes
  • Reason (example: classed plans)
  • Definition (example: class 1 is executives)
  • Employee Attribute (example: executives are employees with salary greater than $50,000)
  • Full census of employees' eligibility (example: spreadsheet of employees per class)

Editing employees' plan eligibility

The client can edit employees' data in the relevant field (increase salary, change answer to Custom Field, etc.) to edit their assignment to a label, via the Directory app, unless the attribute is Manual. If the attribute is Manual (not tied to a field in Zenefits), please utilize your support channel to request employee eligibility be manually updated.

Setting up plan restrictions

Timing for setup is important, since we can't restrict plans that are not live in our system, and plans aren't live in our system until the renewal is built and launched.

  • This means that there is potential risk to launch Open Enrollment to employees before plans have been restricted, and employees may see or elect plans that they're not eligible for.
  • It's recommended to launch to the admin(s) only to allow time for your support representative to complete setup before all employees are given access to Open Enrollment.
    • Employees can later be invited to Open Enrollment from the Renewals Management dashboard.
  • This applies to setting up for the first time and to editing at renewal

Here are some things to keep in mind if you are removing plan restrictions during the renewal or open enrollment period.

  • Restrictions that are rolled over at renewal utilize the same source structure, so editing or removing will impact labels
  • Keep in mind any overlapping eligibility definitions, such as:
  • Class 1 is defined as executive for 2018 and managers for 2019
  • 2019 plans are effective July 1 2019 but are loaded into Zenefits in May
  • 2019  restrictions will have to be edited in consideration of employee eligibility for May 1 through June 30 2019 to avoid gaps or discrepancies
  • Your support representative will ease the transition between restrictions, but please give enough time for them to accommodate

Editing employees' plan eligibility

  • Editing an assignment to a label does not cascade to employee enrollments
    • Example: if Joe is labeled as an executive and enrolled in the Class 1 life plan, and his label is changed to associate instead, he will still be enrolled in the Class 1 life plan in Zenefits and with the carrier
    • You'd have to update the plan and enrollment both with the carrier outside of Zenefits as well as in the Benefits Administration app in Zenefits separate from updating an employee's label
  • Plan eligibility can be viewed in the Benefits Administration app
    • Navigate to the Employees tab
    • Search for the relevant employee
    • Click into the Eligibility tab on the right
    • Scroll down to view plan eligibility*

*Note that this data is only available if plan restrictions have already been set up

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