Job-Based Health Insurance
Employer Health Insurance for People Living With Multiple Sclerosis
Understanding Job-Based Health Insurance Options
- Although many employers in the United States offer group health insurance to their workers, some do not, especially if they have fewer than 50 employees. Sometimes, employers limit their group health plan to full-time workers only or exclude the worker’s spouse. Children up to age 26 are eligible for enrollment in a parent’s job-based health plan even if they are a student, have a job, no longer live at home or are married. If you are unsure about who qualifies for a job-based group health plan, ask your employer or union directly.
Healthcare.gov glossary or ask the plan sponsor for explanations of these terms and how they apply to your coverage." c-nmssatomrichtext_nmssatomrichtext-host=""> Typically, employers, or other group health plan sponsors, pay for most of the insurance premium, and the members contribute a portion. Most of the expenses that people living with MS usually pay are from annual deductible amounts, copayments or co-insurance for covered benefits, plus the full cost of any uncovered or excluded benefits. Check the Healthcare.gov glossary or ask the plan sponsor for explanations of these terms and how they apply to your coverage.FairHealth.org or a cost calculator (typically available on the health insurance provider’s website). - Make use of preventive health services and wellness programs to stay healthy.
- Choose in-network providers, generic drugs and urgent care centers instead of the emergency room whenever possible.
There are a few ways that you can keep costs as low as possible, including:
- Understand how your health plan shares the costs of your care with you.
- Research and compare costs with the help of FairHealth.org or a cost calculator (typically available on the health insurance provider’s website).
- Make use of preventive health services and wellness programs to stay healthy.
- Choose in-network providers, generic drugs and urgent care centers instead of the emergency room whenever possible.
Most plans include an annual out-of-pocket maximum (or limit). These limits are the most you pay during a policy period (usually one year) before your health insurance or plan starts to pay 100% for covered benefits. This limit must include deductibles, coinsurance, copayments or similar charges. Your out-of-pocket maximums must also include expenditures that are required of an individual and are a qualified medical expense for covered benefits. This limit does not have to count premiums, balance billing amounts for non-network providers and other out-of-network cost-sharing or spending for care you receive that is not covered by your plan.
If your job-based health plan ends because you leave a job, become eligible in Medicare, are unable to do your job because of a disability or experience another qualifying event, you have options. You can choose to enroll in COBRA, if available, or buy an individual policy. Enrolling in individual coverage may be significantly less costly if you qualify for a tax credit. To explore options for individual coverage and possible tax credit, go to HealthCare.gov or call 1-800-318-2596. You can also read more about COBRA coverage below.
General information you may need about a job-based plan can be found in materials provided by your employer or plan sponsor. It is always a good idea to get verification of coverage details in writing. If you are unsure how to proceed, call MS Navigator® at 1-800-344-4867.
COBRA and Benefits for People Living with MS
- The Consolidated Omnibus Budget Reconciliation Act of 1986 (COBRA) helps those insured in group health plans keep their coverage when certain events occur, such as switching or leaving a job, ‘aging out’ of a parent’s coverage, getting divorced or gaining eligibility for Medicare. Federal law requires every employer with 20 or more employees to offer COBRA benefits. However, many states go beyond this and require smaller group plans and other federally exempted employers to offer COBRA.
The basic protection COBRA affords is the right to continued enrollment in a group health plan for a certain number of months after coverage would otherwise end. With a few exceptions, all covered employees and their covered spouses and dependents in groups of 20 or more are guaranteed this right as qualified beneficiaries, provided they pay the former employer (or the COBRA administrator) their full portion of the premium plus a 2% surcharge. In other words, the employer no longer pays part of the cost of this coverage, but COBRA makes the group health plan available for individual purchase. - COBRA’s protections are offered to eligible individuals when certain qualifying events occur.
For employees:- Voluntary or involuntary termination of employment for any reason except "gross misconduct."
- A change in an employee's work status to part-time, resulting in the employee's ineligibility for the employer's health plan.
- Voluntary or involuntary termination of the covered employee's employment for any reason except "gross misconduct."
- A change in the covered employee's work status to part-time, resulting in ineligibility for the employer's health plan.
- The covered employee becomes eligible for Medicare.
- Divorce or legal separation from the covered employee.
- Death of the covered employee.
- Loss of dependent child status under the plan rules.
- Employers are required to notify employees about their COBRA rights when they join the group health plan and, most importantly, when they are about to leave the plan because of one of the qualifying events listed above. Qualified beneficiaries have 60 days from the date the COBRA offer is made to notify the employer of their choice to elect or reject continued coverage. Each qualified beneficiary may elect COBRA coverage for themself or a covered employee or spouse may choose COBRA for any other qualified beneficiaries.
COBRA coverage begins on the date the group health coverage would otherwise end. There is no gap. - How long COBRA benefits last depends on who the qualified beneficiary is and what event resulted in COBRA qualification.
- Termination or reduction of work – the standard COBRA benefit period is a maximum of 18 months.
- Disability – If a qualified beneficiary (including a spouse or dependent child, as well as the employee) is considered disabled as determined by the Social Security Administration within their first 60 days of COBRA coverage, they may extend the COBRA continuation period for an additional 11 months, to a total of 29 months. To be eligible for this disability extension, a copy of the Social Security Administration’s disability determination must be provided to the plan administrator within 60 days of its receipt. Note also that the premium will increase 50% more for months 19 to 29.
- Death, divorce or legal separation – COBRA lasts for 36 months if the qualifying event is the death of or divorce/legal separation from the covered employee.
- Qualified beneficiaries must be offered benefits identical to those received immediately before qualifying for COBRA.
- There is no standard cost because group health insurance plans vary. However, because COBRA is an extension of group coverage, the premiums will be lower than those for an individual plan. The employer or COBRA administrator will tell you what your premiums will be at the time COBRA is offered. You may have to pay higher premiums if you get extended coverage.
- Although COBRA specifies the period during which coverage must be offered, it does not prohibit plans from offering longer coverage. So, if your COBRA is due to run out and you have no other health insurance, you can ask if the former employer is willing to let you keep paying the premiums to stay in the group plan.People on COBRA from months 18 to 29 due to disability will pay as much as 50% more for coverage during that extended period.
- When you elect COBRA, you are agreeing to pay the premium for continued health benefits for yourself and possibly, your dependents. Failure to pay in a timely manner can result in termination of coverage, and re-instatement is unlikely.
- All written information you receive from your former employer or COBRA administrator are legal documents and should be kept for your personal protection.