You're not alone if you find yourself occasionally bewildered by
the workings of group
. Questions arise about employees' rights and employers'
We gathered the most common questions from Insure.com readers
and turned to Scottsdale, Ariz.-based benefits expert Lenny
Sanicola for answers. Sanicola is senior practice leader for
WorldatWork, a not-for-profit organization of human resources
professionals that offer education and research focused on global
human resource issues.
Here are answers to the 11 most common group health
1. Is my employer required to offer a group health insurance
No, health insurance is an employee benefit, and employers can
choose whether to offer it.
However, starting in 2014 under the Affordable Care Act,
employers with more than 50 employees will have to pay fees if they
don't offer health insurance coverage and have at least one
full-time worker who qualifies for a premium tax credit. If an
employer refuses to offer health insurance, the law calls for an
assessment of $2,000 per full-time employee, excluding the first 30
2. Can my employer offer a health insurance plan to some
workers but not others?
Yes, at this time an employer does not have to offer
health insurance coverage
to all employees. It can choose to provide coverage based on
employment-based categories, such as full-time versus part-time
workers, or salary versus hourly workers.
"They just have to make sure they treat everyone within a
classification consistently," Sanicola says.
3. Can my employer force me to buy my company's health
If participating in the health plan is part of an employment
contract, then the answer is yes, even if that means you have to
pay part of the premium.
A company might do this to ensure a larger pool of risk for the
company health plan and avoid "adverse selection" by workers who
have health problems.
Some companies ask employees who decline company health plan
benefits to sign statements that they have other coverage in place,
4. Are employers required to pay a portion of health insurance
Most do, but they're not required by law to contribute.
5. Can my spouse's employer refuse to add me to their group
health insurance plan?
Yes, an employer can choose to offer
benefits only to employees, not their family members, but it must
apply the rules consistently, Sanicola says. An employer cannot
discriminate by extending coverage to some employees' family
members but not to others.
6. Can I add my grandchild to my group health insurance
It depends on where you live and on your employer's plan. Some
states mandate that small-group plans extending coverage to family
members allow employees to list grandchildren as dependents. In
other states, some employers might allow grandchildren on the plan
if the children are listed as dependents on the employees' tax
returns or the employees have legal guardianship of the
grandchildren. Check the plan's dependent eligibility requirements
to learn the rules.
7. Does my new group health insurance plan have to cover my
If you've had health insurance through a group
health insurance plan
for 12 months, with no coverage lapse of 63 days or more, then a
new group health plan cannot exclude a pre-existing condition from
coverage, according to Title 1 of the Health Insurance Portability
and Accountability Act. If you were without health insurance or had
a lengthy lapse, then the group plan can refuse to cover a
pre-existing condition for up to 12 months.
Under health reform, a group health plan cannot, however,
exclude coverage of a pre-existing condition of a child under 19.
Starting in 2014, insurance companies will not be allowed to
exclude pre-existing conditions of adults as well.
8. Can my husband and I buy separate family group insurance
plans through our different jobs?
Yes, you can each buy coverage through your individual
employers. The insurance from your employer would be your primary
insurance and the secondary insurance for your husband. The
coverage through your husband's employer would be his primary
insurance and your secondary insurance.
The "birthday rule" would determine which plan was primary for
dependents, Sanicola says. Under the rule, the health plan of the
parent whose birthday comes first in the calendar year is the
designated primary plan for children, and the other parent's health
plan is the secondary insurance.
9. Can my employer ask if I'm covered under my spouse's
Top of Form
Yes, the employer can ask to determine if you have secondary
coverage or if you plan to waive the company health plan.
10. Can my employer impose a waiting period for coverage after
I start a job?
Yes, waiting periods of 30 to 90 days are common in industries
with high employee turnover rates, Sanicola says.
11. Do I have a right to see my group health insurance plan's
You should be able to find all the pertinent details about
coverage in the health plan summary the employer provides. But if
you want to look at the actual policy, then yes, you can ask to see
it, Sanicola says. Your employer can charge copying fees for
reproducing the document for you.
When you have questions about your group health coverage, contact
the insurer or your employer's human resource department. For
questions about state insurance laws governing small-group
coverage, check with your state's insurance department. Most large
employers are self-insured and are regulated by federal, rather
than state, insurance laws.