Life Changes Require Health Choices...Know Your Benefit Options
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 make sure you have the level of health care coverage you need at every stage of your life.
What You Need to Know: When you get married, you can change your health coverage. You can add yourself, your new spouse and children to your employer’s plan, enroll in your spouse’s employer’s plan, or find coverage through the Health Insurance Marketplace (Marketplace). Get the details on all of your special enrollment options and be sure you understand how the different plans work. You'll want to know the benefits covered, the amounts of any deductibles or copays you will be required to pay, what you will pay for premiums, 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, a new spouse, and children in your employer’s plan or your spouse’s employer’s plan within 30 days of your marriage. 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 the information on all options and compare before you decide which health coverage is best for you.
Pregnancy, Childbirth, and Adoption
What You Need to Know: Under the Patient Protection and Affordable Care Act (ACA), many employer plans and all plans purchased through the 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 and adoption (including 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 in a Marketplace plan. Under the Newborns' and Mothers' Health Protection Act (Newborns’ Act), plans that provide maternity or newborn benefits generally must provide coverage for mothers and newborns to stay in the hospital 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, then you may be protected under state law rather than under the Newborns’ Act. Your plan must provide you with a notice regarding 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 your plan covers for maternity and newborn benefits as well as for well-baby and well-child visits. To learn more about your state law’s requirements for hospital stays after childbirth, visit the National Association of Insurance Commissioners’ Website and go to States & Jurisdiction Map to find your state insurance commissioner’s office.
To request special enrollment in an employer plan, you must notify your plan within 30 days of your child's 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" the child may be eligible for coverage under his or her own employer’s plan, for special enrollment in Marketplace coverage or may be eligible to purchase temporary extended health coverage for up to 36 months under the Consolidated Omnibus Budget Reconciliation Act (COBRA). Generally, COBRA covers group health plans maintained by 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 covered child reaching age 26. In turn, your plan should notify your child of the right to extend health care 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 an employer health plan available at work, the spouse and any dependents may be eligible to special enroll in that plan. Or, they may be able to special enroll in health coverage through the Marketplace.
The spouse and any dependent children also may be eligible to continue their existing health coverage for up to 36 months. The plan should notify them of their right to purchase extended health care coverage under COBRA. Most plans require eligible individuals to make their COBRA election of 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’s plan within 30 days of the loss of coverage or select a plan in the Marketplace within 60 days before or 60 days after the loss of coverage.
For COBRA coverage, the employer must notify the plan within 30 days if the employee who is covered by the health care plan dies. If there is a divorce or legal separation, the covered employee, spouse, or dependent children must notify the plan in writing within 60 days. In case of death of the covered employee, divorce, or legal separation, the plan should notify the eligible spouse and dependent children who would lose coverage under the plan of their right to purchase temporary extended health care coverage. 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, there are specific laws protecting your right to health benefits when you lose coverage or change jobs. EBSA also oversees health care laws covering special medical conditions.
Visit the Employee Benefits Security Administration’s Website to view the following publications. To order copies or to request assistance from a benefits advisor, contact EBSA electronically 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
- Your Health Plan and You – Know Your Health Coverage Protections
- 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 at HealthCare.gov or call 1-800-318-2596 to find out more about Marketplace plans. Or contact your state insurance commissioner’s office.