For Consumers

Employee rights under health reform

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Many large employers (more than 50 employees) offer health insurance to their employees. The requirements and benefits are different depending on if your plan is grandfathered or non-grandfathered. If you’re not sure, ask your insurance company or your human resource department.

Large employer health insurance and health reform

As of 2015, large employers must offer affordable insurance to their employees and their dependent children. A plan's considered unaffordable if the employee’s share is more than 9.55 percent of their household income or if the plan pays for less than 60 percent of covered health care expenses.

If your employer offers health insurance, and it's not affordable, you might qualify for a premium subsidy, if you buy a health plan through Washington state’s health insurance exchange (www.wahealthplanfinder.org).

Health reform does not require large employer plans to include the essential health benefits (EHB). However, if the plan does include an EHB, then that benefit has no annual or lifetime dollar limit. See the new reforms and how they apply:

Large employer health plan requirements under health reformNon-grandfathered group plansGrandfathered group plans
Provide you with a “Summary of Benefits and Coverage” (SBC)YesYes
Cannot retroactively cancel your coverage if you made a mistake on your initial application, unless the plan finds fraud or intentional misrepresentationYesYes
Provide health coverage for dependent children until they turn age 26YesYes
Provide coverage for pre-existing conditions for all enrolleesYesYes
Allow discounts and rewards on wellness programs of up to 30 percent on premiumsYesYes
Renew your policy even if you become sickYesYes
Guarantee your right to appeal eligibility and claim denials to independent review organizations (IROs)YesFully funded plan = Yes
Self-funded plan = No
Cover certain recommended preventive care for freeYesNo
Provide you the right to choose your doctor and access to out-of-network emergency room servicesYesFully funded plan = Yes
Self-funded plan = No
May require a waiting period of no more than 90 days before you can enroll in the company's health planYesYes