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Most individuals go through a number of life events that affect their
health benefit needs and the choices they make. There are several important
federal laws that affect your benefits under a job-based health plan. Below is
a list of life events and a brief description of federal laws that may protect
your rights when these events occur. Attached are fact sheets that explain in
more detail these laws.
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ERISA Claims Procedures help ensure timely and fair
review of plan denials of claims.
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Make the Right Health Benefit Decisions When You Get Married
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The Health Insurance Portability and Accountability Act
(HIPAA) offers special enrollment rights for employees and spouses that
allow them to enroll in a group health plan upon marriage and provides
protections for individuals who have preexisting conditions or might suffer
discrimination on the basis of health status when they switch plans.
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ERISA Disclosure Provisions provide individuals with
rights to important information concerning benefits under their own or
spouses group health plan.
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Protect Your Rights When You Have or Adopt a Baby
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HIPAA prohibits preexisting condition exclusions from
being applied to pregnancy, regardless of whether the mother had previous
health coverage. In addition, HIPAA does not permit preexisting condition
exclusions to be applied to newborns and adopted children who enroll within 30
days of birth or adoption.
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HIPAA also offers special enrollment rights for
employees, spouses and new dependents allowing them to enroll in a group health
plan upon birth, adoption, or placement for adoption.
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ERISA Claims Procedures help ensure timely and fair
review of maternity and other claims under group health plans.
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The Newborns and Mothers Health Protection Act includes important new protections for mothers and their newborn children
with regard to the lengths of hospital stays following the birth of a child.
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Keep Health Coverage After a Job Change
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HIPAA protects individuals who have preexisting
conditions, helping them to keep coverage for those conditions or get coverage
for them in no more than 12 or 18 months through limits on the length of
preexisting condition exclusions. HIPAA also helps individuals who might suffer
discrimination in health coverage on the basis of health status when they
change jobs.
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COBRA generally requires that most group health plans of
employers with at least 20 employees offer employees and their dependents the
opportunity to continue their health plan coverage for limited periods of time
when the employee loses his or her job or has a reduction in hours that would
result in a loss of coverage.
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Make Sure Your Loved Ones Have Good Health Care
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ERISA permits a parent to obtain a court order to provide
coverage for children under the noncustodial parents health plan (called
a qualified medical child support order).
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ERISA Disclosure Provisions help to ensure that
individuals covered by group health plans receive clear information about their
rights, benefits, and obligations under the plan, including information about
COBRA continuation coverage, access to urgent or specialized care, and
composition of physician and other provider networks.
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HIPAA includes protections for newborns and adopted
children with preexisting conditions. Specifically, HIPAA does not permit a
preexisting condition exclusion to be applied to a newborn or adopted child who
enrolls within 30 days of birth or adoption.
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Keep Coverage When a Marriage Ends
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HIPAA offers special enrollment rights, generally
allowing employees and dependents who were covered under a spouses plan
to obtain coverage under the employees plan upon divorce or legal
separation, if they are otherwise eligible.
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COBRA generally requires that group health plans of
employers with at least 20 employees offer spouses and dependent children the
opportunity to continue their health care coverage for limited periods of time
in the event of the spouses legal separation or divorce from the employee
covered by the plan.
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Secure the Right Care in Your Later Years
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HIPAA offers protections for individuals who have
preexisting conditions, helping them to keep coverage for those conditions or
get coverage in no more than 12 or 18 months through limits on preexisting
condition exclusions.
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HIPAA includes protections to help ensure individuals are
not excluded from coverage under their group health plan or charged a higher
premium based on health status.
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COBRA generally requires that group health plans of
employers with at least 20 employees offer employees and their dependents the
opportunity to continue their health plan coverage for limited periods of time
when the employee loses his or her job due to retirement.
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ERISA Claims Procedures help ensure fair and timely
appeals process for covered individuals.
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ERISA Disclosure Provisions require that group health
plan disclosure material furnished to plan participants and beneficiaries must
contain information about specialists in the plan network and the plans
rules for accessing specialty care.
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ERISA Disclosure Provisions also require that plan
disclosure material must describe the ability of the employer to reduce plan
benefits or terminate the plan.
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