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Employee Benefits Security Administration

Fact Sheet: Life Events Impact Health Benefit Needs

Most individuals go through a number of life events that affect their health benefit needs and the choices they make. There are several important federal laws that affect your benefits under a job-based health plan. Below is a list of life events and a brief description of federal laws that may protect your rights when these events occur.

Make the Right Health Benefit Decisions When You Get Married

The Health Insurance Portability and Accountability Act (HIPAA) offers special enrollment rights for employees and spouses that allow them to enroll in a group health plan upon marriage and provides protections for individuals who have preexisting conditions or might suffer discrimination on the basis of health status when they switch plans.

ERISA Disclosure Provisions provide individuals with rights to important information concerning benefits under their own or spouse’s group health plan.

Protect Your Rights When You Have or Adopt a Baby

HIPAA prohibits preexisting condition exclusions from being applied to pregnancy, regardless of whether the mother had previous health coverage. In addition, HIPAA does not permit preexisting condition exclusions to be applied to newborns and adopted children who enroll within 30 days of birth or adoption.

HIPAA also offers special enrollment rights for employees, spouses and new dependents allowing them to enroll in a group health plan upon birth, adoption, or placement for adoption.

ERISA Claims Procedures help ensure timely and fair review of maternity and other claims under group health plans.

The Newborns’ and Mothers’ Health Protection Act includes important new protections for mothers and their newborn children with regard to the lengths of hospital stays following the birth of a child.

Keep Health Coverage After a Job Change

HIPAA protects individuals who have preexisting conditions, helping them to keep coverage for those conditions or get coverage for them in no more than 12 or 18 months through limits on the length of preexisting condition exclusions. HIPAA also helps individuals who might suffer discrimination in health coverage on the basis of health status when they change jobs.

COBRA generally requires that most group health plans of employers with at least 20 employees offer employees and their dependents the opportunity to continue their health plan coverage for limited periods of time when the employee loses his or her job or has a reduction in hours that would result in a loss of coverage.

Make Sure Your Loved Ones Have Good Health Care

ERISA permits a parent to obtain a court order to provide coverage for children under the noncustodial parent’s health plan (called a qualified medical child support order).

ERISA Disclosure Provisions help to ensure that individuals covered by group health plans receive clear information about their rights, benefits, and obligations under the plan, including information about COBRA continuation coverage, access to urgent or specialized care, and composition of physician and other provider networks.

HIPAA includes protections for newborns and adopted children with preexisting conditions. Specifically, HIPAA does not permit a preexisting condition exclusion to be applied to a newborn or adopted child who enrolls within 30 days of birth or adoption.

ERISA Claims Procedures help ensure timely and fair review of plan denials of claims.

Keep Coverage When a Marriage Ends

HIPAA offers special enrollment rights, generally allowing employees and dependents who were covered under a spouse’s plan to obtain coverage under the employee’s plan upon divorce or legal separation, if they are otherwise eligible.

COBRA generally requires that group health plans of employers with at least 20 employees offer spouses and dependent children the opportunity to continue their health care coverage for limited periods of time in the event of the spouse’s legal separation or divorce from the employee covered by the plan.

Secure the Right Care in Your Later Years

HIPAA offers protections for individuals who have preexisting conditions, helping them to keep coverage for those conditions or get coverage in no more than 12 or 18 months through limits on preexisting condition exclusions.

HIPAA includes protections to help ensure individuals are not excluded from coverage under their group health plan or charged a higher premium based on health status.

COBRA generally requires that group health plans of employers with at least 20 employees offer employees and their dependents the opportunity to continue their health plan coverage for limited periods of time when the employee loses his or her job due to retirement.

ERISA Claims Procedures help ensure fair and timely appeals process for covered individuals.

ERISA Disclosure Provisions require that group health plan disclosure material furnished to plan participants and beneficiaries must contain information about specialists in the plan network and the plan’s rules for accessing specialty care.

ERISA Disclosure Provisions also require that plan disclosure material must describe the ability of the employer to reduce plan benefits or terminate the plan.

This fact sheet has been developed by the U.S. Department of Labor, Employee Benefits Security Administration, Washington, DC 20210. It will be made available in alternate formats upon request: Voice phone: 202.693.8664; Text telephone: 202.501.3911. In addition, the information in this fact sheet constitutes a small entity compliance guide for purposes of the Small Business Regulatory Enforcement Fairness Act of 1996.