Your Rights under Job Based Health Coverage

From a dollar standpoint, your medical insurance is probably the most valuable employee benefit you receive. In general, if your employer has more than 20 full-time workers, you enjoy broad protection under Federal laws in several key areas.

Getting onto your employer’s plan:
In the past, if you (or one of your dependents) couldn’t answer health history questions to the satisfaction of the insurance company, you could be denied coverage altogether.

Now, if you sign up for the plan within the timeframe specified in the plan, you must be allowed onto the plan.

Full benefits for pre-existing conditions:
In the past, maintaining coverage for on-going medical conditions was dicey at best. “Pre-existing conditions” under new employer’s plans were usually either not covered at all, or covered only after a certain period of time.

Now, if an individual maintains “continuous coverage”, which is defined by Federal law, expenses related to pre-existing conditions must be covered.

Staying covered if you quit, are fired or fall below the number of hours worked to be eligible for the plan:
In the past, if you no longer worked the required number of hours to be eligible for the plan you were typically dropped from the plan often immediately.

Now, by law, your employer is required to inform you, and your covered dependents, in writing-sent by First Class Mail- of your rights to continue coverage and how to go about doing so. If notification is not sent as outlined, your employer/former employer is subject to strict financial penalties.

Expenses related to pregnancy must be covered:
In the past, policies could deny maternity related expenses, either in general, or as a pre-existing condition. No more. Even if you join your plan after your first window of opportunity, your maternity related expenses, or those of your spouse, must be paid by the plan.

Coverage for your dependants in the case of your death:
In the past, if you died while on the medical plan, your covered spouse and/or dependents were probably dumped from the plan immediately.

Now, your surviving family members can stay on the plan, generally for 36 months, if they pay for the coverage.

Coverage for you and/or your dependents if you retire:
In the past, if you retired (falling below the minimum number of hours per week) you, your spouse and/or dependents were probably immediately dumped from the plan.

Now, all must be allowed to stay on the plan for up to 36 months, but you have to pay their monthly premiums.

Coverage in the event of your divorce:
In the past, if you divorced, your former spouse was probably immediately dumped from the plan.

Now, if you notify your employer of your divorce, your ex must be allowed to stay on the plan for up to 36 months, but has to pay for the coverage.

Coverage for dependent children who lose dependent status or student status:
In the past, if your dependent child got “too old” to be on the plan, he/she lost coverage immediately.

Now, if you advise your employer of your dependent’s loss of eligibility due to age or student status, the child must be allowed to stay on the plan for up to 36 months. However, you guessed it, someone must pay the monthly premiums.

In all of these situations, Federal law spells out your rights and responsibilities as well as the responsibilities of your employer. Your employer is required to notify you and your dependents of these rights by first class mail at two times: when you first become eligible for the coverage, and when your coverage (or your dependents’) ends. Many states have complimentary legislation providing even greater protection. Check your plan booklet for information