· In general, 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 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.

· 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. You will not have health insurance during this time.

· When you begin a new job with health insurance through an HMO, the HMO may require an affiliation period before coverage begins. During this affiliation period, you will not have health insurance coverage. The HMO cannot impose any pre-existing condition exclusions if it imposes an affiliation period. An HMO affiliation period cannot exceed 2 months (3 months for late enrollees), and you cannot be charged a premium during it.

· 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 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 plan offers family coverage, your dependents can elect coverage as well. Enrollment during a special enrollment period is not considered late enrollment.

· Under Pennsylvania law, newborns and adopted children are automatically covered under the parent’s fully insured health plan for the 31 days, if the plan covered dependents. The insurer may require that the parent notify the plan and pay a premium within the first 31 days in order to continue coverage beyond the first 31 days.

However, if the plan does not provide for coverage of dependents, the parent has the right to convert – within 31 days after the child’s birth- to a plan which will provide similar benefits.

· Under Pennsylvania law, disabled adult children can remain on their parent’s fully insured group health plan after reaching the age at which dependent coverage is usually terminated, if they meet certain requirements. To qualify, your adult son or daughter must be incapable of self-sustaining employment because of mental retardation or physical handicap. Proof of incapacity must be furnished to the insurer within 31 days of reaching the limiting age and may be required subsequently in the future.

· 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.

· In addition, in Pennsylvania, fully insured group health plans must cover as a dependent your unmarried child under the age of 30 if he or she is unmarried, does not have any dependents, and either lives in the Commonwealth or is a full-time student in an institution of higher learning. 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.

· 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. A new 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.

Read your plan documents carefully to determine when your child will “age off” your group health plan.

· 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 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 for 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 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 on your rights under the FMLA, contact the U.S. Department of Labor.