Employment Law

Health Insurance and Employee Rights

Key Takeaways:

  • Most large employers must offer health insurance for their full-time employees.
  • Employer-provided plans must not discriminate based on preexisting health care conditions.
  • Federal law caps the maximum out-of-pocket costs that someone will have to pay for plan-covered expenses.

Knowing your rights as an employee when it comes to health insurance benefits and getting the coverage you need can be confusing. 

This article answers frequently asked questions about health insurance and your employee benefits. There are different health insurance obligations for different types of businesses, and laws vary from state to state. For specific answers to your questions, you should contact an experienced and local employment lawyer. They can give you legal advice about your rights when it comes to health insurance. 

What Health Insurance Benefits Are Employees Entitled To? 

Whether you are entitled to health insurance from your employer as part of a benefits package depends on several factors, including the company’s size and your job. Most large employers who employ more than 50 full-time employees must offer some type of health insurance for those full-time employees. The scope of coverage and the related costs will vary widely. 

Small businesses or small employers that employ fewer than 50 people do not have to offer health insurance, but they may offer health care coverage for tax benefits.

The federal Affordable Care Act (ACA), also known as “Obamacare,” provides several protections for employer-sponsored health insurance. These protections include prohibiting denial of coverage for preexisting conditions, allowing children to stay on their parents’ plan until age 26, and ensuring coverage for essential health benefits, such as some preventative screenings. 

Additionally, the Consolidated Omnibus Budget Reconciliation Act, also known as COBRA, is a federal law allowing you to remain on your work-provided health insurance if you leave your job. However, your employer will not have to pay their share of premium costs, making your insurance cost much more.

What Is the Difference Between Employer-Sponsored Health Insurance and Individual Health Insurance? 

Employer-sponsored health insurance is health coverage that your employer provides and pays a portion of the premiums. The types of plans, the scope of coverage, and the costs of employer-sponsored health insurance can vary. Individual health insurance is coverage you find and pay for yourself. Individual health insurance is usually found on the federal government’s health insurance marketplace

What Are the Different Types of Health Insurance Plans? 

Common types of health benefit plans for eligible employees include: 

  • HMO (health maintenance organization): These benefit plans require you to choose an in-network primary care physician and get referrals to see specialists for medical care.
  • PPO (preferred provider organization): This type of plan provides more flexibility in choosing doctors and specialists without referrals.
  • EPO (exclusive provider organization): Another plan that covers your medical services only if you use doctors, specialists, or hospitals in the plan’s network (except in an emergency).
  • POS (point of service): This plan allows you to pay less if you use doctors, hospitals, and other health care providers that belong to the plan’s network. POS plans require you to get a referral from your primary care doctor to see a specialist.
  • HDHP (high deductible health plan): This plan features higher deductible costs but lower premium costs. 

How Do I Choose the Right Health Insurance Plan? 

The right health insurance plan for you depends on several factors, including your health care needs, your medications, your age and life insurance needs, whether you want to keep your existing doctor versus having to change networks, your family members’ medical needs, and your financial situation. 

What Are the Out-of-Pocket Costs for Health Insurance? 

Out-of-pocket costs for health insurance can include copays for doctor’s visits, increased costs for specialists, prescription costs, and deductibles. In health insurance, the deductible is how much you must pay before your health insurance carrier will begin to pay your medical costs for you. Your deductible will vary in amount and usually resets every year.  

Under federal law, most health insurance plans have a cap on the out-of-pocket expenses you will pay every year. If you hit the maximum, the insurance company will have to pay the rest of the covered expenses.

What Are the Open Enrollment and Special Enrollment Periods for Health Insurance? 

Open enrollment is the period that your employer designates for you to sign up for health insurance or change your existing health insurance. Employers should allow you to change your existing health insurance with a significant life-altering event like a marriage or the birth of a child or if you lose health insurance due to a spouse’s job loss or some other event. 

Have Questions About Your Health Insurance? 

Your employer’s human resources department can answer many questions related to health insurance plans, open enrollment, and eligibility. You can also call the health insurance company for answers to coverage and network questions. You can visit the healthcare.gov website for answers to some legal questions or contact an experienced employment lawyer.   

Whether your employer must provide you with health insurance coverage depends on your situation. For answers, you should contact an experienced employment law attorney.

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