Illinois Employment Law – Health Insurance Mandates

State health insurance mandates are laws regulating the terms of coverage for insured health plans. Mandates can affect various parts of health insurance plans, as follows:

Benefit mandates require health insurance plans to cover specific treatments, services or procedures.

Provider mandates require health insurance plans to pay for services provided by specific health care professionals. Often, provider mandates are in the form of nondiscrimination mandates that require coverage only if the health plan already reimburses services within the scope of the health care professional’s practice.

Person mandates require health insurance plans to cover specific categories of people.

Additional mandates for health plans exist at the federal level. For example, the Affordable Care Act (ACA) requires non-grandfathered plans in the small group and individual markets to provide coverage for items and services designated as “essential health benefits.” Health plan sponsors and issuers should work with their advisors to determine how to comply with applicable federal and state mandates.

This Employment Law Summary contains charts outlining Illinois’ benefit, provider and person mandates for group health insurance plans issued in Illinois. Please keep in mind that the following charts do not address federal benefit mandates, such as those found in the ACA.

Benefit Mandates

MANDATEDESCRIPTION
AlcoholismPlans that provide inpatient hospital coverage for sickness must cover inpatient treatment of alcoholism.
Amino acid-based elemental formulasPlans must cover amino acid-based elemental formulas, regardless of delivery method, for the diagnosis and treatment of:

•  Eosinophilic disorders; and

•  Short bowel syndrome.

This mandate applies when the prescribing physician has issued a written order stating that an amino acid-based elemental formula is medically necessary.

Autism spectrum disordersPlans must provide coverage for the diagnosis and treatment of autism spectrum disorders for individuals under age 21, subject to an inflation-adjusted maximum benefit of $36,000 per year. This coverage may not be subject to any limits on the number of visits to a service provider, and dollar limits and cost-sharing provisions may not be less favorable than those that apply to physical illness generally.
Blood processingPlans that cover miscellaneous hospital expenses must cover the processing and administration of blood and its components.
Breast cancer painPlans must cover all medically necessary pain medication and therapy related to the treatment of breast cancer on the same terms and conditions that are generally applicable to coverage for other conditions.
Breast examsPlans must cover clinical breast examinations as follows:

•  At least every three years for women between ages 20 and 40; and

•  Annually for women age 40 or older.

Breast implant removalPlans must cover the removal of breast implants when the removal is medically necessary for the treatment of a sickness or injury. This mandate does not apply to implants inserted solely for cosmetic reasons, except for cosmetic surgery performed as reconstruction resulting from sickness or injury.
Cancer treatment – prescription drugs (off-label drug use)Plans that cover prescription drugs approved by the federal Food and Drug Administration (FDA) for the treatment of certain types of cancer may not exclude any drug on the basis that the drug has been prescribed for the treatment of a type of cancer for which the drug has not been approved by the FDA. The drug, however, must be FDA-approved and must be recognized for the treatment of the specific type of cancer for which it has been prescribed. This coverage must also include medically necessary services associated with the administration of a drug.
Cancer trials – routine patient carePlans must cover any routine patient care administered to an insured who is a qualified individual participating in a qualified clinical cancer trial, if the plan covers that same routine patient care for insureds who are not enrolled in a qualified clinical cancer trial. This coverage may be subject to all terms, conditions, restrictions, exclusions and limitations that apply to the same routine patient care received outside of a qualified clinical cancer trial. An insured individual’s out-of-pocket liability for these benefits may not be greater than they would be had the insured not enrolled in a qualified clinical cancer trial.
Colorectal cancer screeningsPlans must cover all colorectal cancer examinations and laboratory tests for colorectal cancer as prescribed by a physician, in accordance with certain guidelines. Plans may not impose any waiting period or cost-sharing requirement that is greater than that imposed on other coverage under the plan.
ContraceptivesPlans must cover all of the following without cost-sharing:

•  Contraceptive drugs, devices and other products approved by the FDA, including those available over-the-counter (but excluding male condoms);

•  Voluntary sterilization procedures;

•  Contraceptive services, patient education and counseling on contraception; and

•  Follow-up services related to the covered contraceptive drugs, devices, products and procedures.

Criminal sexual assaultPlans may not exclude coverage for examination and testing of a victim of a criminal sexual assault.
Dental adjunctive servicesPlans must cover anesthesia and other charges incurred in conjunction with dental care that is provided in a hospital or an ambulatory surgical treatment center to:

•  A child age six or under;

•  A person with a medical condition that requires hospitalization or general anesthesia for dental care; or

•  A disabled individual.

Plans must also cover anesthetics and other charges incurred in conjunction with dental care provided by a dentist to a covered individual in a dental office, oral surgeon’s office, hospital, or ambulatory surgical treatment center if the individual is under age 19 and has been diagnosed with an autism spectrum disorder or a developmental disability.

This coverage may be subject to any limitations, exclusions or cost-sharing provisions that apply generally under the plan. This mandate does not require coverage of dental services.

Diethylstilbestrol (DES)Plans may not contain any exception or exclusion of benefits solely because the mother of the insured has taken DES.
Diabetes self-management, equipment, supplies, etc.Plans must cover outpatient self-management training, equipment and supplies for the treatment of Type 1 diabetes, Type 2 diabetes and gestational diabetes mellitus. This coverage must include regular foot care exams by a physician, along with the following, when they are medically necessary and prescribed by a physician:

•  Blood glucose monitors, including blood glucose monitors for the legally blind;

•  Cartridges for the legally blind; and

•  Lancets and lancing devices.

Cost-sharing for these benefits must be the same as those that apply for other services provided by the same type of provider.

Plans that provide a drug benefit must also cover the following, which must be subject to the same cost-sharing provisions as other covered drugs:

•  Insulin;

•  Syringes and needles;

•  Test strips for glucose monitors;

•  FDA-approved oral agents used to control blood sugar; and

•  Glucagon emergency kits.

Finally, coverage for diabetes self-management training may be limited to the following:

•  Three medically necessary visits to a qualified provider upon initial diabetes diagnosis; and

•  Two medically necessary visits to a qualified provider when a significant change in the patient’s symptoms or medical condition has occurred.

Emergency coverage – under the influencePlans may not, solely on the basis of the insured being intoxicated or under the influence of a narcotic, exclude coverage for any emergency or other medical, hospital or surgical expenses incurred as a result of (or related to) an injury acquired while the insured was intoxicated or under the influence of any narcotic, regardless of whether the intoxicant or narcotic is administered on the advice of a health care practitioner. Coverage for these services may be subject to cost-sharing and limits that are consistent with those applicable to other similar coverage under the plan.
Fertility preservation servicesEffective Jan. 1, 2019, plans must cover medically necessary expenses for standard fertility preservation services when a necessary medical treatment may directly or indirectly cause iatrogenic infertility to an enrollee. Iatrogenic infertility means in impairment of fertility by surgery, radiation, chemotherapy or other medical treatment affecting reproductive organs or processes.
Fibrocystic breast conditionPlans may not contain any exception or exclusion of benefits solely because the insured has been diagnosed as having a fibrocystic breast condition, unless:

•  The condition is diagnosed by a breast biopsy that demonstrates an increased disposition to the development of breast cancer; or

•  The insured’s medical history confirms a chronic, relapsing, symptomatic breast condition.

Habilitative services for childrenPlans must cover medically necessary and therapeutic habilitative services for children under age 19 with a congenital, genetic, or early acquired disorder diagnosed by a physician.
HIV testing (prenatal)Plans that provide maternity coverage must cover prenatal HIV testing.
HPV vaccinePlans must cover an FDA-approved human papillomavirus vaccines.
InfertilityPlans that cover more than 25 employees and provide pregnancy-related benefits must cover the diagnosis and treatment of infertility, subject to certain conditions. An exception to this mandate is available for religious institutions and organizations.
Mammography screening/breast ultrasoundPlans must cover low-dose mammography (including digital mammography) screening for the presence of occult breast cancer as follows:

•  A baseline mammogram for women 35 to 39 years of age;

•  An annual mammogram for women 40 years of age or older; and

•  A mammogram at the age and intervals considered medically necessary by the woman’s health care provider for women under 40 years of age and having a family history of breast cancer, prior personal history of breast cancer, positive genetic testing or other risk factors; and

•  A screening MRI when medically necessary, as determined by a licensed physician.

Plans must also provide coverage for a comprehensive ultrasound screening and MRI if a mammogram demonstrates heterogeneous or dense breast tissue, when medically necessary as determined by a licensed physician.

This coverage must be provided at no cost to the insured and may not be applied to an annual or lifetime maximum benefit.

Mastectomy: breast reconstruction after surgeryPlans that cover mastectomies must also cover prosthetic devices or reconstructive surgery incident to the mastectomy. Coverage for breast reconstruction must include:

•  Reconstruction of the breast upon which the mastectomy has been performed;

•  Surgery and reconstruction of the other breast to produce a symmetrical appearance; and

•  Prostheses and treatment for physical complications at all stages of mastectomy, including lymphedemas.

This coverage must be subject to the deductible and coinsurance conditions applied to the mastectomy. When a mastectomy is performed and there is no evidence of malignancy, coverage may be limited to the provision of prosthetic devices and reconstructive surgery within two years of the mastectomy.

Mastectomy – post surgery carePlans that provide surgical coverage must cover inpatient services following a mastectomy for a length of time determined by the attending physician to be medically necessary, based on certain protocols and guidelines, and upon evaluation of the patient and the coverage for and availability of a post-discharge physician office visit or in-home nurse visit to verify the condition of the patient in the first 48 hours after discharge.
Maternity – post parturition carePlans that provide maternity coverage must provide the following amount of inpatient care:

•  A minimum of 48 hours after a vaginal delivery for the mother and the newborn; or

•  A minimum of 96 hours after a caesarian section delivery for the mother and newborn.

A shorter hospital stay may be provided if the attending physician determines it is appropriate, based on certain guidelines, and depending on the coverage and availability of a post-discharge physician office visit or in-home nurse visit to verify the condition of the infant in the first 48 hours after discharge.

Mental healthPlans must offer coverage for reasonable and necessary treatment and services for mental, emotional or nervous disorders or conditions, other than serious mental illnesses, consistent with mental health parity requirements.
Mental health parity

 

Plans that provide coverage for hospital or medical treatment and for the treatment of mental, emotional, nervous or substance use disorders or conditions must provide that:

•  The financial requirements and treatment limitations applicable to these benefits are no more restrictive than the predominant financial requirements and treatment limitations applied to substantially all hospital and medical benefits covered by the policy; and

•  There are no separate cost-sharing requirements or treatment limitations that are applicable only to these benefits.

This mandate also contains specific parity requirements for aggregate lifetime limits and annual limits and must be interpreted in a manner consistent with federal regulations issued under the federal Mental Health Parity and Addiction Equity Act of 2008.

Mental health – serious mental illnessPlans must cover treatment of serious mental illness and substance use disorders, consistent with mental health parity requirements.

This mandate does not apply to small employers. A “small employer” is one that employed an average of 50 or fewer employees during the preceding calendar year.

This mandate requires coverage based on medical necessity and consistent with the mental health parity requirements, provided coverage for each calendar year may not be less than the following:

•  45 days of inpatient treatment, including substance use disorder treatment in a licensed residential treatment center;

•  60 visits for outpatient treatment including group and individual outpatient treatment;

•  20 additional outpatient visits for speech therapy for treatment of pervasive developmental disorders.

Plans may not include a lifetime limit on the number of days of covered inpatient treatment or the number of covered outpatient visits.

Multiple Sclerosis – preventative physical therapyPlans must cover medically necessary preventative physical therapy for insureds diagnosed with multiple sclerosis, if prescribed by a physician and if the therapy includes reasonably defined goals. This coverage must be subject to the same deductible, coinsurance, waiting period, cost sharing limitation, treatment limitation, calendar year maximum or other limitations as those that apply to other physical or rehabilitative therapy benefits.
Organ transplantsPlans may not deny reimbursement for an otherwise covered expense incurred for any organ transplantation procedure solely because the procedure is experimental or investigational.
Organ transplants – immunosuppressive drugsWhen a prescribing physician has indicated “may not substitute” on a prescription, a plan that covers drugs may not require or cause a pharmacist to interchange another immunosuppressant drug or formulation issued to inhibit or prevent the activity of the immune system of a patient to prevent the rejection of transplanted organs and tissues, without notification and the documented consent of the prescribing physician and the patient, or the parent or guardian if the patient is a child, or the spouse of a patient who is authorized to consent to the treatment of the person.
Osteoporosis & bone mass measurementPlans must cover medically necessary bone mass measurement and the diagnosis and treatment of osteoporosis on the same terms and conditions that generally apply to coverage for other medical conditions.
Ovarian cancer screeningPlans must cover surveillance tests for ovarian cancer for female insureds who are at risk for ovarian cancer.
Pap testsPlans must cover an annual cervical smear or Pap smear test for female insureds.
Pediatric autoimmune neuropsychiatric disordersPlans must cover treatment of pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections and pediatric acute-onset neuropsychiatric syndrome.
Prescription inhalantsPlans that cover prescription drugs must cover prescription inhalants for persons with asthma or other life-threatening bronchial ailments, as often as needed, if medically appropriate and prescribed by the treating physician. Restrictions on refill limits may not apply to these drugs.
Prostate specific antigen testingPlans must cover an annual digital rectal examination and a prostate-specific antigen test for male insureds upon the recommendation of a physician for:

•  Asymptomatic men age 50 and over;

•  African American men age 40 and over; and

•  Men age 40 and over with a family history of prostate cancer.

Prosthetic and orthotic devicesPlans must cover prosthetic and orthotic devices, subject to the plans’ other general exclusions, limitations and financial requirements, under terms and conditions that are no less favorable than those that apply to substantially all medical and surgical benefits under the plan. Repairs and replacements of prosthetic and orthotic devices must also be covered, subject to the copayments and deductibles, unless necessitated by misuse or loss.
Shingles vaccinePlans must cover an FDA-approved shingles vaccine when ordered by a physician for an enrollee who is 60 years of age or older.
TelehealthPlans that cover telehealth services may not require:

•  That in-person contact occur between a health care provider and a patient;

•  The health care provider to document a barrier to an in-person consultation for coverage of services to be provided through telehealth;

•  The use of telehealth when the health care provider has determined that it is not appropriate; or

•  The use of telehealth when a patient chooses an in-person consultation.

Cost-sharing applicable to services provided through telehealth may not exceed the cost-sharing required for the same services provided through in-person consultation.

Temporomandibular joint disorder (TMJ)Plans must offer coverage for the treatment of TMJ and craniomandibular disorder. The maximum lifetime benefit for these services may be limited to no less than $2,500. 

Provider Mandates

MANDATEDESCRIPTION
ChiropractorPlans that cover services within the scope of these providers’ licenses must cover the services regardless of whether these providers or a physician provides the services, as long as the treatment and services are within the scope of the providers’ licenses.
Dentist
Physician/Osteopath
Podiatrist
Optometrist
Alcohol and drug abuse practitionersPlans that cover treatment of alcoholism or other drug abuse or dependency on both an inpatient and outpatient basis must include coverage for services provided by persons or entities licensed by the Illinois Department of Human Services to provide alcoholism or drug abuse or dependency services, provided that:

•  The charges are otherwise eligible for reimbursement under the plan; and

•  The services provided are medically necessary and within the scope of the provider’s license.

Autism diagnosis and treatment providersPlans must cover the diagnosis of autism spectrum disorders, which includes tests, evaluations or assessments that are prescribed, performed or ordered by a licensed physician or a licensed clinical psychologist with expertise in diagnosing autism spectrum disorders.

Coverage for medically necessary early intervention services must be delivered by certified early intervention specialists, as defined under Illinois regulations. The treatment for autism spectrum disorders includes care that is prescribed, provided, or ordered by a licensed physician or a certified, registered, or licensed health care professional with expertise in treating effects of autism spectrum disorders when the care is determined to be medically necessary and ordered by a licensed physician.

Habilitative services providersPlans must cover habilitative services for children administered by a licensed speech-language pathologist, licensed audiologist, licensed occupational therapist, licensed physical therapist, licensed physician, licensed nurse, licensed optometrist, licensed nutritionist, licensed social worker or licensed psychologist upon the referral of a physician.
HospitalsPlans may not deny a claim for treatment or services for:

•  Mental illness rendered in a hospital solely because such hospital lacks surgical facilities; or

•  Rehabilitation following either a physical or mental illness rendered in a hospital solely because such hospital lacks surgical facilities.

Mental health providersEach insured that is covered for mental, emotional or nervous disorders or conditions must be free to select the licensed physician, licensed clinical psychologist, licensed clinical social worker, licensed clinical professional counselor, licensed marriage and family therapist, licensed speech-language pathologist or other licensed or certified professional at a program licensed under the Illinois Alcoholism and Other Drug Abuse and Dependency Act of his or her choice to treat such disorders, and the insurer must pay the covered charges of the health care provider up to the limits of coverage, provided that:

·       The disorder or condition treated is covered by the plan, and

·       The health care provider is authorized to provide the services under state statutes and in accordance with accepted principles of his or her profession.

Prosthetic and orthotic device providersPlans must cover prosthetic or custom orthotic devices from any licensed prosthetist, licensed orthotist or licensed pedorthist.

Person Mandates

MANDATEDESCRIPTION
Adopted childrenPlans that provide family coverage may not exclude a child from coverage or limit coverage for a child solely because the child is adopted or does not live with the insured.
Civil union partners/familiesPlans that provide family coverage must cover the parties of a civil union on the same basis as they cover married individuals. If a plan provides coverage for children, children of civil unions must also be covered.
Continuation for dependent childrenAn employee’s dependent child who is covered under a plan must be offered continuation coverage if group coverage would otherwise end due to:

•  The child’s attainment of the policy’s limiting age; or

•  The employee’s death, if coverage is not available through spousal continuation.

The continuation coverage may last for a maximum period of 2 years.

Continuation for employeesEmployees who have been continuously covered under a policy for at least three months and whose coverage would otherwise end because of termination of employment (other than because he or she committed a felony or theft in connection with work) or reduction in hours may elect to continue coverage for themselves and their eligible dependents for a maximum period of 12 months.
Continuation for spouseAn employee’s spouse and dependent children who are covered under a plan must be offered continuation coverage if group coverage would otherwise end due to dissolution of marriage or death of the employee (for a spouse of any age), or due to the employee’s retirement (for a spouse who is age 55 or older). For spouses who have not reached age 55 at the time continuation coverage begins, coverage may last for a maximum period of 2 years. For spouses who have reached age 55 at the time continuation coverage begins, the maximum coverage period may last until the date of Medicare eligibility.
ConversionAn employee who has been covered under a group policy for at least three months and whose insurance under the group plan has been terminated for any reason (except discontinuance of the plan in its entirety where there is a succeeding carrier and the employee’s failure to pay any required contribution) must be entitled to a conversion policy without evidence of insurability. The converted policy must cover the employee and his or her dependents who were covered on the date of termination of insurance. Conversion privileges are also available upon the employee’s death or when a spouse or dependent child loses eligibility under the group plan. Conversion policies must also be offered following continuation coverage.
Dependent coverage – young adultPlans that provide family coverage must cover unmarried young adults up to age 26 (or age 30 for military veterans) who meet any other eligibility requirements that apply under the plan. Plans may not condition dependent eligibility on enrollment in an educational institution.

For military veterans to qualify for dependent coverage up to age 30, the veteran must:

•  Be an Illinois resident;

•  Have served as a member of the active or reserve components of any of the branches of the Armed Forces of the United States, including the National Guard; and

•  Have received a release or discharge other than a dishonorable discharge.

Dependent coverage- disabledIf coverage would terminate because a dependent child attains a plan’s limiting age, the child’s hospital and medical coverage must continue if he or she is:

•  Incapable of self-sustaining employment; and

•  Dependent on his or her parents or other care providers for lifetime care and supervision because of a condition that occurred before the child reached the limiting age.

Dependent students – medical leave of absencePlans must continue to provide coverage for a dependent college student who takes a medical leave of absence or reduces his or her course load to part-time status because of a catastrophic illness or injury. This continuation may terminate 12 months after notice of the illness or injury or, if earlier, when the coverage would have otherwise lapsed.
Extension of benefits– total disabilityPlans must provide a reasonable extension of benefits (up to 12 months) in the event of total disability on the date the policy is discontinued for any reason.
Newborn childPlans that provide family coverage must cover a newborn child from the moment of birth, if the newborn meets the definition of “dependent” under the plan. This coverage must include illness, injury, congenital defects, birth abnormalities and premature birth, to the extent the service, supplies and treatments are covered under the plan. Notification and premium payment may be required.
Surviving dependentsUpon the death of an insured employee, dependent coverage, if any, must continue for a period of at least 90 days subject to any other plan provisions relating to termination of dependent coverage.

STATE RESOURCES

Illinois Department of Insurance – http://insurance.illinois.gov/

Illinois Laws – Illinois’ statutes are available here

Group Health Insurance Plans

Making decisions about health insurance probably isn’t at the top of your list of favorite things to do. However, health insurance is an important part of your finances and medical care, so you want to make an educated choice about which plan to enroll in. If you are offered group health insurance through your employer, you can take advantage of several benefits.

What Are Group Health Plans?

Group health insurance plans are employer-based plans that offer coverage to a pool of employees. In contrast, an individual plan is purchased to cover only one person or family. The difference between how group and individual plans are designed affects your costs.

Why Choose a Group Health Plan?

Group health insurance plans hold several advantages over individually purchased health insurance, including lower costs and convenience.

  • Shared risk. Because a group plan covers multiple people, the risk is spread out over what is likely a fairly healthy group of participants. This helps keep your premium rates lower than individual plans whose rates are based on individual risk.
  • Shared costs. With group coverage, your monthly premium is even lower because the cost is shared between you and your employer. Employers will pay varying percentages of coverage, but whatever amount they choose, it reduces the amount you owe. Depending on your employer’s benefits, you may be responsible for the full cost of the premium for your enrolled family members, or your company may choose to contribute to those premiums as well.
  • Tax advantages. If you pay health insurance premiums for an employer-sponsored group health plan, you can pay your premium with pre-tax dollars, which means you are not taxed on the money that is spent on your premium. This lowers your taxable income, giving you another financial benefit from group health coverage. If you are enrolled in an individual health plan, your premium will typically be paid with taxed dollars.
  • Easy enrollment. A huge advantage of group health coverage through your employer is the ease of enrolling and paying. Your employer will handle the administrative burden of facilitating coverage, and typically your premiums will be automatically deducted from your paychecks.
  • COBRA. Under certain circumstances, such as voluntary or involuntary job loss, you have the option to keep your group insurance plan for a certain length of time under the Consolidated Omnibus Budget Reconciliation Act (COBRA). You will have to pay more for the premium because your employer is no longer paying a share of the cost, but it is an option available to you while you work on acquiring new medical coverage after a job loss or other qualifying circumstance. For more information on COBRA, visit www.dol.gov/dol/topic/health-plans/cobra.htm.

 

Individual Health Insurance

Individual health insurance is health coverage that is purchased by an individual or a family and is not tied to a job or a group of policyholders.

Many people get health insurance through their employers. However, if you do not currently participate in your employer’s health plan, or if your employer doesn’t offer coverage, obtaining individual insurance is a good route to go to ensure that you and your family will receive affordable routine health care and will be protected from very high costs in the event of a medical emergency.

The following is an overview of different types of coverage and where you can get them.

 1. Obtain Insurance in the Individual Market

Obtaining an individual policy can be expensive. Before purchasing, it is important to shop around for the best plan with the lowest premium. In general, a low premium means higher out-of-pocket costs when you need care; a high premium means lower out-of-pocket costs. You’ll also want to make sure you are covered in case of a major medical accident and also for preventive care.

2. Shop for Coverage Using the Health Insurance Marketplaces

The Health Insurance Marketplaces (also known as Exchanges) are a new way to buy health insurance and apply for Medicaid. Created by the ACA, the Marketplaces are designed to help you easily find health insurance that fits your budget.

Eligible individuals can shop for coverage using the Marketplaces. Qualified health plans in the Marketplaces are sold and run by private companies, and every plan covers a core set of 10 essential health benefits, which include emergency, prescription drug and mental health services. Additionally, all plans offered in the Marketplace must provide free preventive care, with 100 percent of the costs paid for by insurance companies.

Extended coverage policies are broken down into four categories: bronze, silver, gold and platinum. The category you choose affects how much your premium costs each month and how much you pay for things like hospital visits or prescription medications. Depending on your income, you may even be eligible for an advance payment tax credit that lowers your monthly premium right away.

Under the ACA, no qualified health plan can refuse to cover people with pre-existing conditions. You will have guaranteed coverage and renewability, regardless of a pre-existing condition (like cancer or diabetes), gender, age, etc. There is also a “catastrophic” plan option available to young people and low-income individuals.

3. Get on Your Parent’s, Spouse’s or Domestic Partner’s Plan

If your spouse or domestic partner has an employer-sponsored plan that is open to family members, consider joining and enrolling your children. The ACA extended coverage for young adults up to age 26 on plans offering dependent coverage, regardless of their marital or student status.

4. Obtain Insurance Through COBRA and State-sponsored Programs

If you recently left your job or had your hours reduced and were subsequently dropped from employer-based coverage, you may be able to obtain coverage under the Consolidated Omnibus Budget Reconciliation Act (COBRA).

After you leave your job, your former employer no longer pays for any of your insurance costs. Therefore, when you have COBRA coverage, you usually have to pay the entire premium yourself, plus a small administrative fee. As a result, COBRA coverage can be very expensive.

Your state may have laws that complement federal COBRA regulations and other protection statutes, such as mini-COBRA plans. If you work for an employer with 20 or fewer employees, your state may have mini-COBRA laws that allow you to obtain benefits.

5. Obtain Insurance Through Protections Under HIPAA

Under the Health Insurance Portability and Accountability Act (HIPAA), at least one private insurer must sell you a policy if you meet all of the following conditions:

  • You previously had 18 months of coverage without a break for more than 63 days
  • The last day of your coverage was through your former or current employer
  • You do not have a COBRA or mini-COBRA option available

6. Determine Whether you are Eligible for Medicaid or Other State Programs

Medicaid provides health coverage for some low-income individuals, including families and children, pregnant women, the elderly and people with disabilities. People who do not qualify for full Medicaid benefits may still be eligible for breast cancer and cervical cancer screenings or for assistance with certain treatments.

The rules for Medicaid enrollment differ slightly from state to state. You can visit www.medicaid.gov or use your state’s Marketplace to determine whether you are eligible for Medicaid coverage in your state. You can also consult your local health department to see if there are any public coverage options available in your area.

In addition, the ACA established a temporary reinsurance program to reimburse participating employment-based plans for a portion of the cost of providing health insurance coverage to early retirees and their spouses, surviving spouses and dependents. If you or your spouse has recently retired, you may qualify for this coverage.

With all the different health plans available out there, it can be difficult to select the plan that best meets the needs of you and your family, and, ultimately, your budget. While it can be tempting to pick the plan with the lowest premium, you don’t want to be is surprised by high out-of-pocket costs or network restrictions when seeking medical care. For more information about your coverage options, or for help selecting the best health plan for you, contact Snyder Insurance Services today.