· You have to be eligible for the group health plan. For example, your employer may not give health benefits to all employees such as part-time, non-permanent, or seasonal employees. Or, your employer may offer an HMO plan that you cannot join because you live outside of the plan’s service area.
· You cannot be turned away or charged more because of your health status. Health status means your medical condition or history, genetic information, or disability. This protection is called nondiscrimination. Employers may refuse or restrict coverage for other reasons (such as part time employment) as long as these are unrelated to health status and applied consistently.
Discrimination due to health status is not permitted
The Acme Company offers two different health plans. Full time employees are offered a high option plan that covers prescription drugs; part time employees are offered a low option plan that does not. This is permitted under the law. By contrast, in a cost-cutting move, Acme restricts its high option plan to those managers who can pass a physical examination. This is not permitted under the law.
· You must be given a special opportunity to sign up for your group health plan if certain changes happen to your family or other health insurance coverage. In addition to any regular enrollment period your employer or group health plan offers, you must be offered a special opportunity to enroll in your group health plan after certain events. Depending on the event, these special enrollment periods can last either 30 or 60 days. You can elect coverage at this time. If your group health plan offers family coverage, your dependents can elect coverage as well. Enrollment during a special enrollment period is not considered late enrollment.
Certain changes can trigger a special 30-day enrollment opportunity
· The birth, adoption, or placement for adoption of a child
· Marriage
· Loss of other coverage (for example, that you or your dependents have through yourself or another family member because of death, divorce, legal separation, termination, retirement, or reduction in hours worked)
Certain changes can trigger a 60-day special enrollment opportunity
· Loss of eligibility under Medicaid or SCHIP
· Eligibility for a state Medicaid or SCHIP premium assistance subsidy applicable to premiums for a group plan
· Under Kentucky law, newborns are automatically covered under your fully insured group health plan for the first 31 days following birth. Adopted children and children placed for adoption are automatically covered if the plan covers dependents. The insurer may require that the parent enroll the child within the 31 days and pay higher premiums in order to continue coverage beyond the 31 days.
· If your group health plan covers dependents, you may be able to keep your son or daughter covered under the plan after the age of majority. Most group health plans will allow your son or daughter to remain covered under your family plan past the age of 19 if they are a full time student.
If your son or daughter is in college and covered as a dependent under your group, but cannot maintain student status due to illness, he or she may still be able to remain covered as your dependent for up to one year. Federal law allows dependent children who take a medical necessary leave of absence due to a serious illness or injury to remain covered as dependents under their parents’ group plan for up to one year or until the coverage would otherwise end, whichever comes first. This law will apply to plan years beginning on or after October 9, 2009.
In addition, in Kentucky fully insured group health plans that provide coverage for dependents must cover as a dependent your unmarried child up to age 25. This law does not apply to self-insured group health plans. Check with your employer to find out the kind of group health plan you have.
Read your plan documents carefully to determine when your child will “age off” your group health plan.
· When you begin a new job, your employer may require a waiting period before you can sign up for health coverage. These waiting periods, however, must be applied consistently and cannot vary due to your health status. Unlike employers, insurance companies cannot require waiting periods. If your new job has health insurance through an HMO, the HMO may also require a waiting period called an HMO affiliation period, and you will not have health insurance coverage during this time. An affiliation period cannot exceed 2 months (3 months for late enrollees), and you cannot be charged a premium during this period.
· If you have to take leave from your job due to illness, the birth or adoption of a child, or to care for a seriously ill family member, you may be able to keep your group health coverage for a limited time. A federal law known as the Family and Medical Leave Act (FMLA) guarantees you up to 12 weeks of job-protected leave in these circumstances. If you qualify for leave under the FMLA, your employer must continue your health benefits. You will have to continue paying your share of the premium.
The FMLA applies to you if you work at a company with 50 or more employees.
If you qualify for leave under the FMLA, your employer must continue your health benefits. You will have to continue paying your share of the premium.
If you decide not to return to work at the end of the leave period, your employer may require you to pay back the employer’s share of the premium. However, if you don’t return to work because of factors outside your control (such as a need to continue caring for a sick family member, or because your spouse is transferred to a job in a distant city), you will not have to repay the premium.
For more information about your rights under the FMLA, contact the U.S. Department of Labor.
