When an employee chooses to not enroll in coverage because she has other coverage, she may once again become eligible to enroll, if she loses her former insurance coverage, or if contributions towards the other coverage cease. The employee has the option to enroll, but must do so within 31 days of loss of coverage, … Continue reading WHAT CONSTITUTES SPECIAL ENROLLMENT RIGHTS? →

When a plan allows premiums to be paid on a pre-tax basis, restrictions on when changes can be made usually apply. Commonly, an employee’s election stays in effect for the entire plan year and changes are not permitted, except during annual open enrollment. However there are exceptions, at any time throughout the year, an employee … Continue reading WHAT CONSTITUTES A QUALIFYING CHANGE IN STATUS? →

CHIPRA is the Children’s Health Insurance Program Reauthorization Act (2009), and allows states to subsidize premiums for health insurance coverage provided by employers (both fully insured and self-insured) for eligible children. CHIPRA is a state and federal partnership, associated with Medicaid, that provides affordable health coverage for the children in families that earn too much … Continue reading WHAT IS CHIPRA? →

COBRA is the Consolidated Omnibus Budget Reconciliation Act of 1985; this law allows former employees to remain on an employer’s insurance plan for a limited amount of time. The coverage offered to them must be identical as the coverage offered to active employees, although participants pay the full employer cost, and at times an additional … Continue reading WHAT DOES COBRA DO? →

HIPAA stands for “The Health Insurance Portability and Accountability Act of 1996”, it is a law that impacts all aspects of health care: Provides the ability to transfer and continue health insurance coverage for millions of Americans when they change/lose their jobs; Prevents health care fraud and abuse; Mandates industry-wide standards for health care information … Continue reading WHAT DOES HIPAA MEAN? →

A “pre-existing condition” is a health condition that exists before someone applies for or enrolls in a new health insurance policy. Insurers generally define what constitutes a pre-existing condition. Usually, preexisting conditions are any medical conditions for which treatment was received or should have been received. While insurers generally determine the presence of a pre-existing … Continue reading WHAT DOES PRE-EXISTING CONDITION MEAN? →

Precertification means that the plan approval must be obtained before a procedure can be started. Also known as pre-authorization, a plan has the ability to impose penalties if precertification is not obtained prior to the procedure. Penalties may include denying the claim in its entirety, imposing a financial penalty or paying a reduced amount. When … Continue reading WHAT DOES PRECERTIFICATION MEAN? →

PHS, or Public Health Service Act, Section 2708, provides that starting in 2014, a group health plan will not apply a waiting period in excess of 90 days for the employee to become eligible for coverage. However, the act does not distinguish between full time and part time employees, but does indicate that a full … Continue reading WHEN IS AN EMPLOYEE ELIGIBLE TO PARTICIPATE IN A PLAN? →

Yes, an employer has the option of imposing surcharges if an employee’s spouse is eligible for another employer’s coverage, yet declines said coverage in order to enroll with spouse. The employer may impose an additional surcharge for having to cover that spouse.

Yes, an employer has the option of imposing surcharges for behavioral patterns. If the surcharge is contingent upon the employee completing a behavior or wellness program, an alternative method must also be made available to any employee unable to meet the requirements provided.