• 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 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. 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 (for example, if you work less than 30 hours per week or only on a temporary basis) as long as these are 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 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. 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 Washington law, newborns, adopted children and children placed for adoption are automatically covered under the parent’s fully insured health plan, if the plan covers dependents. The automatic coverage only lasts for the first 60 days following the birth or adoption. The insurer may require that the parent notify the insurer of the birth within 60 days and pay higher premiums in order to continue coverage beyond the 60 days.
• Under Washington law, your disabled children can remain covered under your fully insured group health insurance plan after he or she reaches the age at which dependent coverage usually terminates. To qualify, your adult son or daughter must be incapable of self-support because of developmental disability or physical handicap and must be chiefly dependent on the policyholder for support and maintenance. Proof of incapacity must be furnished within 31 days of reaching the time limit and may be required periodically thereafter.
• When you begin a new job, your employer may require a waiting period before you can sign up for the group health plan. These waiting periods, however, must be applied consistently and cannot vary due to your health status. You will not have health insurance coverage during this time.
• 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 a 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 do not 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.

• Under Washington law, your protections to keeping your health insurance during family and medical leave may be more protective than under federal FMLA.

Under the Washington Family Care Act, if you work for an employer who provides a paid leave benefit (sick time, vacation, holiday PTO, and some short -term disability plans), you can use that paid leave to care for sick family members, including spouses, children, parents, parent in-laws and grandparents, with a serious health condition. During this time, you may be able to keep your group health insurance. 

Under the Washington Family Leave Act, you may be permitted to take leave for pregnancy or childbirth for up to 12 weeks in addition to the time otherwise permitted under federal FMLA for other reasons besides pregnancy or childbirth. During this time, you may be able to keep your group health insurance.

Finally, under Washington Human Rights Commission law,  if you are pregnant  and work for a business with 8 or more employees, you may be able to take leave for as much time needed before or after childbirth as long as your medical provider determines that you to work. During this time, you may be able to keep your group health insurance. 

To learn more about your rights under The Washington State Family Leave Act and Washington State Human Rights Commission law, and how these laws coordinate with federal FMLA, contact the Employment Standards Office of the Washington State Department of Labor and Industries at 1-866-219-7321 or visit them online at  http://www.lni.wa.gov/. 

In addition, if your questions are related to pregnancy or childbirth related leave, also contact the Washington State Human Rights Commission at 1-800-233-3247 or online at http://www.hum.wa.gov/