Labor and Employment

Employee Benefit Health Care Plans FAQs

Do you have an employee health care plan? Most Americans get their health insurance through their employer. There are many federal laws that protect and regulate your health care benefits. The US Department of Laborprovides information about many of these laws and their regulations. Here are answers to some frequently asked questions about employee benefit health care plans.


Q:

What exactly is a group health care plan?


  • A:

    It's a medical plan provided by your employer to cover employees directly or through insurance. Employee organizations, like a union, can also establish a group health care plan.


Q:

Are there any federal laws that provide protections regarding group health care plans?



Q:

What type of group health plans does ERISA not cover?


  • A:

    It normally doesn't cover health plans by government entities, churches or those maintained only to comply with certain laws.


Q:

Does ERISA cover private sector health care plans or only group health plans through an employer?


  • A:

    ERISA generally covers private sector health care plans also.


Q:

Do I have the right to see the info on my employee health care plan?


  • A:You have the right to see a Summary Plan Description under ERISA that contains info about your plan.


Q:

What information is included in the Summary Plan Description?


  • A:

    It contains information about the important features of your health care plan, including your rights, how your plan works and what benefits are available.


Q:

Am I entitled to be notified of any material changes to my health care plan?


  • A:

    If there are material changes, you're entitled to a revised Summary Plan Description or a different document called a Summary of Material Modifications.


Q:

If there are material changes to my health care plan, when must I be informed of these changes?


  • A:

    If the changes reduce your benefits, you must be informed with 60 days of the changes. If the changes don't reduce your benefits, you must be informed within 210 days after the plan year ends in which the changes are adopted.


Q:

How do I know if I'll be covered under the health care plan of my future wife?



Q:

Is there anything I have to do to qualify for the special enrollment period under my future wife's health care plan?


  • A:

    Your future spouse must request special enrollment for you within 30 days of the marriage. The plan may require the request to be in writing.


Q:

Can my employee health care plan treat a pregnancy as a pre-existing condition?


  • A:

    Pregnancies can't be considered pre-existing conditions under HIPAA.


Q:

How far back can my health care plan look for pre-existing conditions?


  • A:

    The HIPAA limits a health care plan to only six months to be able to look back for pre-existing conditions.


Q:

Can my health care plan exclude a condition even though I never received medical care for the condition?


  • A:

    No, your plan can only exclude pre-existing conditions for which you sought medical advice or treatment during the six months prior to when you enrolled in the plan.


Q:

How long can my health care plan exclude my pre-existing condition?


  • A:

    The exclusion period is 12 months for most people. It increases to 18 months if you enroll late.


Q:

What federal agency is responsible for enforcing these health care laws?



Q:

My employer just declared bankruptcy. What should be my next step?


  • A:

    You should find out the status of your plan and its benefits from the plan's administrator. Your Summary Plan Description will let you know how to get in touch with the administrator.


Q:

If my employer is reducing my coverage because of a bankruptcy, am I entitled to any type of notice?


  • A:

    You're entitled to notice within 60 days of the reduction.


Q:

My employer failed to pay my health claim and has now filed for bankruptcy. What do I do?


  • A:

    You can file a proof of claim with the bankruptcy court to seek payment.


Q:

My employer terminated all employee health care plans. If I quit my job, can I continue my health coverage through COBRA?


  • A:

    No, COBRA coverage won't be available. You'll have to find other health care coverage.

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