Getting Health Insurance at Work

If your employer offers health coverage, you should check the different options for both you and your family members (dependents). Don't be afraid to ask questions. It's important to remember that employers can refuse or restrict coverage for some reasons. But, employers and health insurers cannot deny or restrict coverage because of a pre-existing health condition, such as cancer. And they cannot limit benefits for a pre-existing condition. Once you are covered by an insurance plan, they cannot refuse to cover treatment for a pre-existing condition.

What is employer-based or group health insurance?

Employer-based (work-based) health plans are set up for groups of people. Group health plans usually cover employees of the same company, and often their dependents. Some employers pay part of employee health care premiums, which are the monthly payments required to continue coverage. Unions and other organizations can also offer group health insurance to their members.

Signing up for health insurance at work

Usually, you can sign up for a health plan for yourself and your dependents when you first start a new job. Your employer can potentially require an “orientation period” of no more than one month, followed by a waiting period of no more than 90 days before you and your dependents can access your coverage. The 90-day waiting period must start one day after the orientation period ends. After that, it’s usually possible to add yourself, a spouse, or a child to a work health insurance policy. The open enrollment period for all employees usually happens once a year and lasts for a week or two. If you’re not sure when this is, you can find out from your health insurance administrator at work. This person is usually in the human resources or employee benefits department.

Changes in your situation

You might also be able to sign up for coverage even when it isn’t open enrollment if you or your spouse had a change in situation (see list below) that resulted in you or a family member needing health coverage. Check with your health insurance administrator at work about your situation, and how quickly you must sign up.

Usually you can add yourself or a dependent to a workplace health insurance policy without waiting for the open enrollment period if you need insurance because any of the following occurred:

• You got married
• You became legally separated or got a divorce
• You or your spouse was laid off or quit a job
• You or your spouse retired or became disabled
• You had a baby
• You adopted a child
• Your spouse lost health insurance due to change in job or no longer qualifies for insurance at work
• Your spouse’s policy is no longer offering insurance to them
• Death of your spouse resulting in loss of insurance that covered you or your child

Learn more about each health plan offered at work

Read carefully when choosing from health insurance and managed care options. There’s usually a chance to compare different types of coverage during open enrollment periods. You can also ask your health insurance administrator for the Summary of Plan Benefits (SPB) at any time. The SPB is an easy to read comparison of what each plan covers.

It’s important to know ahead of time if the plan you’re considering is one of the grandfathered plans or a self-insured plan in which coverage is limited (with things like annual caps and pre-existing condition exclusions). If either of these apply, there may be important limits on your coverage. Check with your health insurance administrator at work before you sign up. At that time, you can also ask if the health plan you’re considering is self-insured.

Plans that meet the Affordable Care Act (ACA) requirements don’t allow pre-existing condition exclusions,annual caps on amount they’ll pay, or charging you more because of your health problems.

If you or your dependent have cancer it’s especially important to choose a health insurance plan that best meets your needs, and doesn't have a cap on what will be paid. When comparing plans, consider a number of factors, including:

• What are the total benefits covered by the plan?
• What are all of the costs associated with the plan, including monthly premiums, deductibles, co-pays, and co-insurance?
• Are your providers (primary care doctor, cancer doctors, facilities, and specialists) included in the network of doctors and hospitals covered by the plan?
• What is the out-of-pocket limit for you or your family? The out-of-pocket limit typically counts the money you pay for deductibles, co-pays, and co-insurance. It often does not include out-of-network services and “non-essential” health benefits or treatments the plan doesn’t cover.
• Does the plan cover your prescription drugs?

Should I consider an individual policy?

In general, job-based group insurance is better for most people than individual insurance. But if you learn that coverage at your job will cost you more than 9.12 % of your income, you may find a better deal in your state’s health insurance Marketplace. The percentage of income used to determine insurance affordability is inflation adjusted, so check with healthcare.gov to find the current rate.

Can I get help with premiums on the Marketplace if I don’t sign up for insurance at my job?

Sometimes. If your income is low enough, you can qualify for help with premiums or other costs. If your individual coverage at work costs 9.12% or less of your household income, you can shop on the Marketplace but you won’t get help with premiums.

Can I shop the Marketplace if family or dependent health coverage costs too much at work?

Yes. Sometimes even when an employee’s individual coverage is affordable (if it meets the 9.12% cutoff noted above), family or dependent coverage is not. In this case, the employee can get their coverage at work, and shop on the Marketplace to try and get lower-cost coverage for the family. Since the employee's individual coverage is affordable, only the family or dependent may be eligible for savings through the Marketplace.

What you need to know

• You or spouse must be employed
• Employees may be able to get dependent coverage to include a spouse and children until they turn 26
• Employer may pay all or part of the premium; employee’s share may be deducted from pay
• Employee must choose a plan
• Premium costs may be high, especially for family coverage
• If you lost insurance or there was a status change in your family (see list), you may be allowed to sign up at times other than open enrollment.
• Some job-based plans don’t have to meet all the requirements (some might have caps, pre-existing condition exclusion periods, or other problems)
• If the employer-based coverage you’re offered has very high premiums compared to your pay, you may still qualify to shop the Marketplace