• In general, you have to be eligible for the group health plan. For example, your employer may not offer health benefits to all 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 reasons unrelated to health status and applied consistently.

Discrimination due to health status is not permitted

The Acme Company has 200 employees and 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 employees 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. In addition to any regular enrollment period your employer or group health plan offers, you must be offered a special, 30-day opportunity to enroll in your group health plan after certain events. You can elect coverage at this time. If your group 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 enrollment opportunity

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  • The birth, adoption, or placement for adoption of a child
  • Marriage
  • Loss of other coverage (for example, that you or your dependents had through yourself or another family member and lost because of death, divorce, legal separation, termination, retirement, or reduction in hours worked)
• If your fully insured employer coverage covers minor children, it must cover newborns and newborns of dependents from the moment of birth. If you are adopting a foster child who resides with you, the child must be covered from date of filing of petition to adopt and thereafter, or, for adopted children, immediately upon placement for adoption. A premium may be charged for this additional coverage. The insurer may require notification of the birth, adoption, or placement for adoption to keep this coverage in place.
• Under Massachusetts law, disabled adult children can remain on their parent’s group health plan after reaching the age at which dependent coverage is usually terminated if they meet certain requirements. The adult child must be mentally or physically incapable of self-sustaining employment and remain dependent on parents for support. Proof of incapacity must be furnished to the plan within 31 days of the child reaching the age at which dependent coverage would normally end.
• When you begin a new job, your employer may require a waiting period before you can sign up for health coverage. This waiting period, however, must be applied consistently and cannot vary due to your health status.
• 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.

The FMLA applies to you if you work at a company with 50 or more employees.

If you qualify for leave under 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 health insurance 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.

Under Massachusetts law, female employees of employers with between 6 and 50 employees are eligible for eight weeks of leave for birth or adoption of a child under the age of three.  In addition, an eligible employee can have a total of 24 hours of leave during any 12-month period, in addition to leave available under the federal act, to participate in his or her child’s school activity or to accompany a son, daughter, or elderly relative to routine medical appointments.

For more information about your rights under the FMLA, contact the U.S. Department of Labor.