Employment-related health insurance frequently asked questions

Note: Due to health reform, as of Jan. 1, 2014, renewed group health plans can no longer deny coverage due to health issues. However, they can impose a waiting period of no more than 90 days before health coverage begins.

If I leave my employment, when is my employer allowed to take me off the group health plan?

Generally, health insurance ends either on your last day of work or the end of the month in which you last worked. Review your benefits information to find out exactly when your coverage ends or check with your employer’s human resource office.

According to federal law, how long can my family stay on my employer’s plan after I leave my employment?

Generally, you may stay on the plan on a self-pay basis for 18 months. Read the COBRA overview for basic information. You can find additional information and answers to questions about your rights under this federal law in the U.S. Department of Labor’s (DOL’s) COBRA publication (www.dol.gov). To order a copy, call DOL’s Publication Hotline at 866-444-3272.

My plan has denied my claim for a benefit that is mandated under Washington state law. My employer says they don’t have to comply with state law because their plan is self-funded. Is my employer correct?

Yes. If your employer self-funds the plan and contracts with an insurance company to provide administration services only, then under the Federal Employee Retirement Income Security Act (ERISA), your employer’s plan is exempt from many state requirements.

However, you have a right to appeal any decisions of the plan. Your appeal rights in your employee benefits plan are required by ERISA. Generally, you have 180 days to file an appeal about any decisions the plan administrator makes. The plan then has 60 days to respond in writing to your appeal.

For complete information about your appeal and other rights under federal employee-benefit laws, contact the Department of Labor's (www.dol.gov) local office in Seattle at 206-757-6781, or call their Publications Hotline at 866-444-3272.

I want to change jobs. Can the new employer’s plan deny me enrollment into the plan due to a pre-existing health condition?

Your employer’s group health insurance plan cannot deny you or your dependents enrollment into the plan based on medical history. You cannot lose your insurance just because you get sick. Also, insurers cannot charge you more money based on your health or past insurance claims.

If I get health insurance through my employer, is there a federal law that limits how my plan will exclude my pre-existing condition?

Under health reform, group health plans that renew on or after Jan. 1, 2014, cannot deny you coverage due to health issues. Until your plan renews, the following rules apply:

  • The Health insurance Portability and Accountability Act (HIPAA) of 1996 limits the pre-existing conditions health insurance plans can exclude from coverage.
  • The only pre-existing conditions your insurance plan may exclude are for those you received or someone recommended you receive medical advice, diagnosis, care, or treatment during the six months prior to your enrollment date. Your enrollment date is your first day of coverage or, if there is a waiting period, it’s the first day of your waiting period (typically, your date of hire).
  • If you had a medical condition in the past, but you have not received any medical advice, diagnosis, care, or treatment for it within the six months prior to enrolling in the plan, your old condition is not considered a pre-existing condition. As a result, an exclusion does not apply.
  • Washington state law shortened this six-month period to three months for group insurance policies for employers that have 50 or more employees.

Legally, what is the limit on the group insurance pre-existing condition exclusion?

Under health reform, group health plans that renew on or after Jan. 1, 2014, cannot deny you coverage due to health issues. Until your plan renews, the following rules apply:

  • For self-funded employers, the federal Health Insurance Portability and Accountability Act (HIPAA) permits health plans to require a 12-month pre-existing condition exclusion period.
  • For large groups (more than 50 eligible employees), state-regulated health insurers may require a three-month pre-existing condition exclusion period.
  • For small groups (1-50 eligible employees), state-regulated health insurers may require a nine-month pre-existing condition exclusion period.

I changed employment and my new group health plan imposes a pre-existing-condition exclusion period. How does my new plan determine the length of my pre-existing-condition exclusion period?

Under health reform, group health plans that start on or after Jan. 1, 2014, cannot deny you coverage due to health issues. Until your plan renews, the following rules apply:

  • Under federal HIPAA law, your new plan must reduce your maximum pre-existing-condition exclusion period by the number of days you had creditable coverage in your last health insurance plan. However, the HIPAA law does not require your plan to take into account any days of creditable coverage that precede a break in coverage of 63 days or more (significant break in coverage).
  • For example, suppose you had coverage for two continuous years followed by a 70-day break in coverage and you then resumed coverage for eight months. You would only receive credit for the eight months of coverage. You would not receive credit for the two years of coverage prior to the 70-day break in coverage.
  • For state-regulated large- and small-group insurance plans, state law lengthens the significant break in coverage to 90 days. However, these plans must reduce your maximum pre-existing-condition waiting period
    to only the amount of time you had continuous, similar coverage under an immediately, preceding health insurance.

Updated 03/27/2014

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