• You have to be eligible for the group health plan. For example, your employer may not give health benefits to all employees. Or, your employer may offer a health maintenance organization (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. 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 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 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 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 have through yourself or another family member because of death, divorce, legal separation, termination, retirement, or reduction in hours worked)
• Under Ohio law, newborns, adopted children and children placed for adoption are automatically covered under the parent’s fully insured health plan for the first 31 days, if the plan covers dependents. The insurer may require that the parent enroll the dependent within the 31 days in order to continue coverage beyond the 31 days.
• In Ohio, disabled dependents are permitted to remain insured under their parent’s fully insured group health plan after they reach the age at which dependent coverage is usually terminated. The adult dependent must be unmarried, incapable of self-sustaining employment by reason of mental retardation or physical handicap and must rely on the policyholder for support. In addition, proof of dependency and disability must be provided to the insurer within 31 days of the dependent reaching the limiting age and periodically after that.
• 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. Small employers offering fully insured health plans may not impose waiting periods longer than 90 days.
• When you begin a new job with health insurance through an HMO or HIC, the HMO/HIC may require an affiliation period before coverage begins. You will not have health insurance coverage during this time. An affiliation period cannot exceed 60 days (90 days if you are a late enrollee), and you cannot be charged a premium during it.
• 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 plan for a limited time. A federal law known as a 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 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 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.

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