Health insurance overview
Employer-sponsored health insurance
Employers decide on coverage and costs
- Employers are not required to provide or pay for health insurance for employees or their family members.
- If an employer offers health insurance, it must be available to all eligible employees. Many employers offer health insurance only to fulltime employees.
- Employers decide how much of the insurance premium they will pay for employees and family members, and the amount employees must pay. Under some circumstances, the insurance company can require that the employer pay a specific percentage of the premium.
- Generally, insurers that offer employer plans that cover family members must allow children to stay on their parent's plan until age 26. This takes effect when your plan first renews on or after Sept. 23, 2010.
- Employers pick the insurance company and choose the benefits available to employees. There may be one plan or several plans. Employers can also require employees to take the employer's health plan and to pay their share of the costs.
- A health insurer cannot decline to provide insurance to an employee or the employee's family members (if the employer offers family coverage) because of medical conditions.
- For employees age 19 or older, employer-sponsored health insurance can impose a waiting period of up to six months for coverage of pre-existing conditions. This period can be up to 12 months if you are a late enrollee or work for a self-insured employer (who is regulated by the federal government, not the state). This waiting period can be reduced or eliminated by the length of time the insured person had continuous insurance coverage with no break in coverage of more than 63 days.
- Employees under age 19 are entitled to immediate treatment of any pre-existing conditions
under federal law.
- Insurers covering small groups (2-50 employees) may not treat pregnancy as a pre-existing condition.
- Group plans purchased through an insurance company must cover certain services, such as treatment for chemical dependency, mental health and mammograms. Find the list of requirements here: http://www.cbs.state.or.us/external/ins/sehi/mandated_health_provisions.pdf
- Many large employers self-insure their employee health plans. This means they don't buy a policy from an insurance company, but instead, pay the benefits directly from company funds. These plans are regulated by the U.S. Department of Labor and not by your state insurance department. The Affordable Care Act is a federal law and self-insured employers are subject to its requirements. See: http://www.dol.gov/ebsa/
When you sign up/change insurance choices
- When you are hired, make sure you understand your deadline for enrolling in your employer's insurance. After this initial enrollment period, you generally must wait until the annual open enrollment to change coverage. However, special enrollments are allowed when there are certain events such as marriage, births, loss of job, etc.
- The insurance company may increase rates annually. The employer decides whether your share of the costs go up. Any changes in cost and coverage typically are shared with employees during the annual open enrollment, when you make decisions about the insurance choices your employer offers.
Tip: Take advantage of open enrollment
Open enrollment is the one time a year you can rethink the insurance choices you made and consider new coverage options offered by your employer. Your human resources or benefits office will typically provide information on any changes in coverage and costs. With few exceptions (such as adding or removing a family member from coverage), you will have to live with your decision for a year. Don't miss this opportunity to learn all you can!