 | | | Frequently Asked Questions: Employer-Sponsored Health Coverage in Workforce Re-Entry | | | | | | | | |
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1) What is employer-sponsored health coverage? |
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This is coverage that pays a portion of the total cost for medically related expenses, such as doctor visits, hospital stays, prescription drugs, and durable medical equipment. Your employer pays for some (or all) of your premium. Each plan summary contains what the plan covers. |
2) How do you obtain employer-sponsored health coverage? |
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Employers allow you to sign up for coverage during specific time periods. These periods may be called by different names, such as initial enrollment, open enrollment, or open season. If you don't sign up when you're first eligible, pre-existing condition exclusionary periods might be longer than they would otherwise be. |
3) Who is eligible for employer-sponsored health coverage? |
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Employer sponsored plans can't turn you down based on your medical history.
If an employer offers coverage, there are a minimum number of hours an employee is required to work in a week to obtain and maintain eligibility for benefits, called an active work requirement. Employers and insurers determine this time period.
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4) How soon will I be eligible for benefits from employer-sponsored health coverage? |
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If you meet the active work requirement you may be required to work for the employer for a certain period of time prior to becoming eligible to enroll in benefits. This may be called a service wait or eligibility waiting period. |
5) What types of employer-sponsored health coverage are there? |
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| Employers may provide a single coverage plan or offer multiple plans to choose from. |
6) If I have a new diagnosis, what do I need to know to access employer-sponsored health coverage? |
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Employer-sponsored plans cannot deny you coverage based on your medical history. They can, however, decide to not cover you for pre-existing conditions for a certain period of time, called an exclusionary period. There are limits to how long these periods can be. If you sign up for your plan after your initial enrollment period, these periods might be longer than they otherwise would be if you signed up on time. |
7) What is a pre-existing condition? |
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For employer-sponsored health coverage, according to federal and state law, a pre-existing condition is any treatment, diagnosis, advice, or care that you received or was recommended within 6 months prior to your enrollment. |
8) What is a pre-existing condition exclusionary period? |
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Some policies have a specified period of time from the start of your coverage that the policy will not cover a pre-existing medical condition. The pre-existing condition will normally be covered once that specified time has gone by. |
9) Can I use current or previous health coverage to deal with pre-existing condition exclusionary periods? |
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Yes! Previous coverage can be used as credit to reduce pre-existing condition exclusionary periods. The federal Health Insurance Portability and Accountability Act (HIPAA), along with similar California law, states that any health coverage, including Medi-Cal (Medicaid) or Medicare, reduces or eliminates pre-existing condition exclusionary periods. This happens when you have had previous health coverage within the last 63 days. That health coverage will reduce the pre-existing condition exclusionary period. California allows a 180 day gap for those whose prior coverage was from an employer, and who lost that coverage because employment ended or the employer stopped offering or contributing to health coverage |
10) What are the limits to pre-existing condition exclusionary periods? |
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For fully-insured plans in California that you sign up for on time, the limit is 6 months. If you sign up late, that limit can be extended until 12 months. HMOs are allowed to have either a 6 month exclusionary period or a 2 month affiliation period, but not both. For self-insured plans, the limit is 12 months (18 for late enrollees). |
11) What prescription drug coverage comes with employer-sponsored health coverage? |
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This depends on the employer-sponsored plan. Some plans provide prescription coverage as a part of the health plan. In some situations prescription drug coverage will be a separate plan. |
12) How much will employer-sponsored health coverage cost and who pays for it? |
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You may be responsible for no cost, a percentage of the cost, or the amount associated with the cost of the coverage that is above what the employer elects to pay. This is determined by employer agreements with their insurance companies. Your employer's Human Resources department or personnel staff can explain these benefit details. You also may be responsible for copayments, coinsurance, and deductibles. |
13) How long will this coverage last? |
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You must meet the active work requirement, pay any portion of the premium you're responsible for, and follow the plan's rules. If you do those things, the coverage will generally last as long as you work for your employer, assuming that the employer continues to offer health coverage. When coverage ends, you may be eligible to continue on the same policy through state or federal continuation coverage protections, such as Cal-COBRA, COBRA, and OBRA.
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14) Does what I have in the bank and/or what I own affect my eligibility for employer-sponsored health coverage? |
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No. There are no limits on what you own or have in the bank for this coverage. It is an insurance program based on premiums paid through an employer. |
15) Can I qualify for employer-sponsored health coverage while I am eligible for or receiving coverage through Medi-Cal or Medicare? |
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Yes. Being eligible for or receiving coverage through Medi-Cal or Medicare does not prevent you from enrolling in and using employer-sponsored health coverage. Enrolling in employer-sponsored health coverage does not affect your eligibility for Medi-Cal and Medicare. It may improve your health coverage options. |
16) How do I stay enrolled and/or eligible in employer-sponsored health coverage? How often do I have to reapply? |
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Employers usually do not require re-enrollment in coverage. You will need to continue to work the minimum number of hours to maintain eligibility for benefits , called an active work requirement. During the annual open enrollment or open season, whether you are working or in continuation coverage, you can change coverage plans. NOTE: Employers may change coverage plans or coverage choices for you without your active participation during these annual periods. |
18) How does changing jobs with a pre-existing condition affect my eligibility for employer-sponsored health coverage? |
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19) What other benefit programs are available to me and how will they work with employer-sponsored health coverage? |
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Some employers may offer dental, vision and long term care coverage in addition to employer-sponsored health coverage. |
20) What about Medi-Cal and employer-sponsored health coverage? |
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Medi-Cal may be available to pay premiums and, in some cases, copays for services not covered by employer-sponsored health coverage. DB101's Medi-Cal program description has an explanation of the Health Insurance Premium Payment (HIPP) program. If you also use or have access to Medi-Cal, it is up to you whether to disclose this to an employer. It is not mandatory. |
21) What else should I be aware of? |
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Health coverage rules can change periodically. Public health coverage ( Medi-Cal and Medicare) and how it interacts with employer-sponsored health coverage is an area where the rules can change more often. When in doubt, contact a benefits planner. |
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