Your Rights under Job Based Health Coverage

Those employees working for a company that offers a group health insurance plan should be aware of the key points regarding that employer’s responsibility as it relates to the health insurance policy. There are minor differences that may exist from one state to another, but for all intents and purposes the rules are the same.

Employers will usually only make the health insurance benefit available to their full-time employees, which leaves the part-timers high and dry. In fact, there have been a number of companies that were prosecuted for purposely limiting the work time for their employees to keep them just below the cut-off to be eligible for such benefits. One thing that most people don’t know is that the state defines a full-time employee differently than most employers do when determining group health plan eligibility; to be eligible to participate in an employer-sponsored group health insurance plan, an employee must work an average of at least 25 hours per week.

This means that any employee with enough working hours must be offered the opportunity to participate in the plan. However, there are ways employers can get around this rule, and that is to define classes of employees and simply exclude certain ones. This is most commonly done in restaurant settings where the administration is offered health insurance benefits, yet the wait staff is not, despite the fact that they work full-time.

Another important fact that employees should know is that the company is only responsible for contributing 10% of the premium. Most employers, in fact, contribute closer to 50% in order to keep the entire group eligible because fewer workers are able to participate if they must pay 90% of the insurance cost. A group is unable to get a health insurance plan if more than 25% of the eligible employees do not participate. The only caveat to this rule is an employee who is considered an Eligible Waiver, meaning that he is covered under another group plan elsewhere through another employer or a spouse’s employer.

Employers cannot force their workers to participate in a health insurance plan, nor prohibit those who are eligible from enrolling. Additionally, in those cases where employers offer multiple plans, an employer cannot restrict a worker’s enrollment in a more expensive plan if that worker is willing to pay the increased premium.

The most important fact that employees should know regarding their rights with employer-sponsored health insurance plans is that their privacy is still entirely protected. Regardless of the situation, the details of a health insurance claim, the size of the company, or how much of the premium is being paid by the employer, every aspect of an employee’s medical treatment and interaction with providers is entirely confidential. No employee is under any obligation to disclose the details of a health insurance claim, or provide treatment details, to anyone, including the employer. Insurance companies and physicians are also legally obligated to keep patient information confidential, and are prohibited from discussing any specifics with employers.

By understanding the rules of eligibility surrounding small group health insurance policies, employees can better prepare themselves for dealing with potential problems in the future. Insurance laws have been designed to protect the insurance companies from fraud, and protect the privacy and safety of the people covered by such companies, and knowing the law is the best way to protect yourself.