You might not be too happy to find out what rules a group health
plan can impose.
We enlisted two industry experts to help us answer some of the
most common questions from Insure.com readers regarding health
plans at work: Arlene Lieberman is a principal in the employee
benefits practice at Barney & Barney in San Diego, and Teagan
Storck is a benefits administrator at Argus Benefits in
Atlanta.
Can I get out of my employer's health plan if I already
enrolled for the next year?
Enrolling for the next year locks you in unless you have an
"event" that qualifies you to get out.
"You would be allowed to cancel coverage if you experience a
change in status or qualifying event," Storck says. A change in
status would be switching from permanent employment to temporary,
full-time to part-time, or any other instance that makes you
ineligible for coverage. A qualifying life event includes marriage,
divorce, birth or adoption of a child, change in your spouse's
employment or other event. Here's
more from the Department of Labor
.
Notify your human resources department within 30 days of the
event and be prepared to provide proper documentation such as a
marriage license (followed by the certificate when it arrives), a
copy of a new health insurance card showing the effective date or a
screenshot of the enrollment.
Can an employer require a worker to be on the company health
plan? If not, under what circumstances?
"If the employer pays 100 percent of the employee-only premium,
then all benefit-eligible employees could be required to
participate in the plan," Lieberman says. You would be required to
enroll only if this is documented in the insurance contract.
However, if the employer requires an employee to make a premium
contribution, it
cannot
mandate that all eligible employees participate in the plan.
Can an employer require me to tell them about a spouse's health
insurance coverage?
Yes, employers can require you to reveal your spouse's insurance
situation. According to Storck, most employers will take the
employee's word without requiring proof, such as documentation from
the spouse's employer, an insurance card, or certificate of
credible coverage. They may also ask for proof that a spouse does
not have access to coverage. This is often in the form of a letter
from the spouse's human resources department.
Can my employer impose a surcharge if my spouse is on the
company health plan but is eligible for a health plan at his/her
own workplace?
Yes.
Most of Storck's clients have added a spousal surcharge if the
spouse has an option for coverage elsewhere but is on the
employee's plan. These surcharges generally range from $25 to $50
per month and are charged whether or not the spouse participates in
his or her own employer's health plan.
Can my employer remove my spouse off the company health plan if
they become eligible for another group health plan?
Yes, says Lieberman.
"A spouse's eligibility on another health plan is considered a
qualified event, which allows the spouse to be removed from the
employee's plan," she says. Notification of the event must be
provided to the employer within 30 days. The employee will not need
to wait until the next open enrollment to make the change.
Does an ex-spouse have to stay on an employee's health plan
until the next open enrollment period if the employee doesn't
promptly notify the company of a divorce?
No.
"In most cases, an ex-spouse is terminated from the plan and
notified of their
COBRA continuation rights
at the time that the employee notifies their employer of the
divorce," Lieberman says.
Can an employer kick someone off the company health plan when
they're eligible for Medicare?
No. An employer cannot drop an employee or a spouse from the
company's health plan if they become eligible for Medicare.
Leiberman explains the criteria that determine the primary payer
for claims:
- If the group is more than 20 employees, then the group
coverage is primary and Medicare is secondary.
- If the group is fewer than 100 employees
and
the spouse is disabled, Medicare will be primary and the group
plan is secondary.
- For groups of more than 100 employees, the group plan is
primary unless the disabled insured has been receiving dialysis
for 39 months, in which case Medicare will be primary.
Here's
more from Medicare
about primary and secondary payers.
For more answers about group health plans, read
Hey, can my employer do that?