If you know your benefit options, you can better protect yourself and your dependents. With some basic information, you can take common-sense steps to have the health coverage you need at every stage of your life.
Marriage
What You Need to Know: When you get married, you can change your health coverage by:
- Adding yourself, your new spouse, and children to your employer's plan,
- Enrolling in your spouse's employer's plan, or
- Finding coverage through the Health Insurance Marketplace.
Get the details on your special enrollment options and be sure you understand how the different plans work. Find out the benefits covered, the deductibles, copays and premiums you will pay, and whether you can continue with the same doctors.
What You Need to Do: To qualify for special enrollment into an employer's plan under the Health Insurance Portability and Accountability Act (HIPAA), you must request enrollment for yourself, your spouse, and children in your employer's plan or your spouse's employer's plan within 30 days after you marry. If you choose to enroll in coverage through the Marketplace, you must select a plan for yourself and your family within 60 days of getting married.
Review and compare all options before you decide which health coverage is best for you.
Pregnancy, Childbirth, and Adoption
What You Need to Know: Under the Affordable Care Act (ACA), many employer plans and all plans purchased through the Health Insurance Marketplace must include benefits for pregnancy, childbirth, and newborn care. Most plans also cover well-baby and well-child care with no copayment, coinsurance or deductible as long as you use a network provider.
Birth, adoption, and placement for adoption may trigger a special enrollment period during which you, your spouse, and new dependents can enroll in your employer's plan or a Marketplace plan. Under the Newborns' and Mothers' Health Protection Act, plans that provide maternity or newborn benefits generally must provide coverage for mothers and newborns for hospital stays of at least 48 hours following a vaginal delivery or 96 hours following a cesarean section, unless the doctor or other attending provider, in consultation with the mother, discharges earlier. If your state has a law that provides similar protections and your plan offers coverage through an insurance policy or HMO, you may be protected under state law rather than under the Newborns' Act. Your plan must provide you with a notice of your rights to a hospital stay following childbirth. If your plan is insured, the notice must describe your protections under state law.
What You Need to Do: Review your plan's Summary Plan Description (SPD) and Summary of Benefits and Coverage (SBC) to find out what maternity and newborn benefits and well-baby and well-child visits your plan covers. To learn more about your state's requirements for hospital stays after childbirth, visit the National Association of Insurance Commissioners' Website to find your state insurance commissioner's office.
To request special enrollment for your child in an employer plan, you must notify the plan within 30 days of the birth, adoption, or placement for adoption. The child's coverage will be effective on the date of the birth, adoption, or placement for adoption. Your plan may require that the notice be in writing.
If you choose to enroll your child in Marketplace coverage, you must do so within 60 days of the birth, adoption, or placement for adoption.
When Your Child is No Longer a Dependent
What You Need to Know: If your employer's plan offers coverage for dependent children, your child can stay on your plan until age 26. Once your child "ages out," they may be eligible for:
- Coverage under their own employer's plan,
- Special enrollment in Marketplace coverage, or
- The purchase of temporary health coverage for up to 36 months under the Consolidated Omnibus Budget Reconciliation Act (COBRA). Generally, COBRA covers group health plans of employers with 20 or more employees.
What You Need to Do: To special enroll in Marketplace coverage, your child must enroll within 60 days of aging out of your plan. To elect COBRA coverage, you must notify your employer in writing within 60 days of your child reaching age 26. Your plan should notify your child of the right to extend their health benefits under COBRA. Your child will have 60 days from the date the notice was sent to elect COBRA coverage.
Death, Legal Separation, and Divorce
What You Need to Know: When an employee covered under an employer-sponsored health plan dies, legally separates, or divorces, the covered spouse and dependent children need to consider their options for health coverage. If the spouse has a health plan at work, they and any dependents may be eligible to special enroll in it. Or they may special enroll in Health Insurance Marketplace coverage.
The spouse and dependent children also may be eligible to continue their existing health coverage for up to 36 months under COBRA. The plan must notify them of their right to purchase COBRA coverage. Most plans require eligible individuals to elect COBRA coverage within 60 days of the plan's notice.
What You Need to Do: To special enroll in health coverage, the spouse and dependent children must request special enrollment in the spouse's employer-provided plan within 30 days of losing coverage or select a Marketplace plan within 60 days before or after losing coverage.
For COBRA coverage, the employer must notify the plan within 30 days if a covered employee dies. If the covered employee and spouse divorce or legally separate, they or their dependent children must notify the plan in writing within 60 days. For these life changes, the plan must notify the spouse and dependent children of their right to extend their health benefits. Most plans require eligible individuals to make their COBRA election within 60 days of the plan's notice.
For More Information
The Department of Labor's Employee Benefits Security Administration (EBSA) administers several important health benefit laws governing your employer-provided health plan – how it works, how you qualify for benefits, your basic rights to information, and how to make claims for benefits. In addition, specific laws protect your right to health benefits when you lose coverage or change jobs.
Visit EBSA to view the following publications. To order copies or to request assistance from a benefits advisor, contact EBSA or call toll free 1-866-444-3272.
- An Employee's Guide to Health Benefits Under COBRA
- Retirement and Health Care Coverage…Questions and Answers for Dislocated Workers
- Top 10 Ways to Make Your Health Benefits Work for You
- Work Changes Require Health Choices…Protect Your Rights
You also may visit the U.S. Department of Health and Human Services Website or call 1-800-318-2596 to find out more about Marketplace plans. Or contact your state insurance commissioner's office.