Getting Health Insurance at Work

If your employer offers health coverage, you generally can’t be turned away or charged more because of your or your child’s health status. But employers can refuse or restrict coverage for other reasons (such as part-time employment), as long as these reasons are not related to your or your child’s health and are applied to all employees.

What is employer-based or group health insurance?

Employer-based (work-based) health plans are set up for groups of people. Group health plans usually cover employees of the same company, and often their dependents. Some employers pay part of employee health care premiums, which are the monthly payments required to continue coverage. Unions and other organizations can also offer group health insurance to their members.

Many people get insurance coverage through a group plan offered by their employer or their spouse’s employer. Under the Affordable Care Act, employers with 50 or more full-time workers must offer health insurance to their employees or pay a penalty. Although many employers offer coverage for spouses or dependents, they’re not required to do so. Employers with fewer than 50 full-time workers are not required to offer health insurance.

Signing up for health insurance at work

Usually, you can sign up for a health plan for yourself and your dependents when you first start a new job. After that, it’s usually possible to add yourself, a spouse, or a child to a work health insurance policy during open enrollment at work. Enrollment happens once a year and lasts for a week or two. If you’re not sure when this is, you can find out from your health insurance administrator at work. This person is usually in the human resources or employee benefits department.

Changes in your situation

You might also be able to sign up even when it isn’t open enrollment if you or your spouse had a change in situation (see list below) that resulted in you or a family member needing health coverage. Check with your health insurance administrator at work about your situation, and how quickly you must sign up. In general, you have about 30 days after the change took place to add someone to a job-based plan.

Most often you can add yourself or a dependent to a workplace health insurance policy without waiting for the open enrollment period if you need insurance because:

  • You got married
  • You became legally separated or got a divorce
  • You or your spouse was laid off or quit a job
  • You or your spouse retired or became disabled
  • You had a baby
  • You adopted a child
  • Your spouse lost health insurance due to change in job or no longer qualifies for insurance at work
  • Your spouse’s policy is no longer offering insurance to him or her
  • Death of your spouse resulting in loss of insurance that covered you or your child

If you or your spouse has recently lost health coverage, most work insurance plans will allow an employee to sign up for their group health insurance any time. You can also add a new family member if need be. This should be done as soon as possible after the change takes place.

Find out about more about each health plan offered at work

Read carefully when choosing among health insurance and managed care options. There’s usually a chance to compare different types of coverage during open enrollment periods. You can also ask your health insurance administrator for the Summary of Plan Benefits (SPB) at any time. The SPB is an easy to read comparison of what each plan covers. You can read more about the main types of health insurance plans in Types of Health Insurance Plans. There is also a worksheet to help you compare how much each plan will cost. Keep the administrator’s phone number and email address handy for questions about the plan and network coverage.

It’s important to know ahead of time whether the plan you’re considering is one of the grandfathered plans or a self-insured plan (See If Your Health Insurance is Grandfathered/Self-Insured for more information) in which coverage is limited (with things like annual caps and pre-existing condition exclusions). Check with your health insurance administrator at work before you sign up to find out if you’re signing up for a plan that existed before March of 2010. At that time, you can also ask if the health plan you’re considering is self-insured. If either of these apply, there may be important limits on your coverage.

Most plans are newer and meet the Affordable Care Act requirements that don’t allow pre-existing condition exclusions, annual caps on amount they’ll pay, or charge you more due to your health problems. If someone in your family has cancer, you’ll want to be sure that the plan you choose will cover pre-existing conditions without a waiting period and doesn’t have a cap on what they’ll pay.

If you or your dependent have cancer it’s especially important to choose a health insurance plan that best meets your needs. When comparing plans, consider a number of factors, including:

  • What are the total benefits covered by the plan?
  • What are all of the costs associated with the plan, including monthly premiums, deductibles, co-pays, and co-insurance?
  • Are your providers (primary care doctor, cancer doctors, facilities, and specialists) included in the network of doctors and hospitals covered by the plan?
  • What is the plan’s out-of-pocket limit for you or your family? The out-of-pocket limit typically counts the money you pay for deductibles, co-pays, and co-insurance. It often does not include out-of-network services and “non-essential” health benefits or treatments the plan doesn’t cover.
  • Does the plan cover your prescription drugs? For some ideas on looking at this, see the American Cancer Society Cancer Action Network (ACS CAN) document Tips for Choosing a Health Insurance Plan with the Best Prescription Drug Coverage for You.

You might also have a preference for what type of insurance you want (see Types of Health Insurance Plans) . Some people prefer a fee-for-service plan while others like an HMO (Health Maintenance Organization) plan, and there are a number of other types.

Should I consider an individual policy?

In general, job-based group insurance is better for most people than individual insurance. But if you learn that coverage at your job will cost you more than 9.5% of your income, you may find a better deal in your state’s health insurance Marketplace.

Should I change jobs to get better benefits?

If you’re happy in your job, you may not want to change for better benefits. But, you could look into buying the more important benefits like health insurance on your own. You could also talk with your employer about the benefits they offer. To keep good workers, some employers are willing to add or improve benefits. But if your employer can’t make any changes and you can’t afford to pay for benefits, then it might be time to look for another good job with better benefits.

Good benefits are an important part of your earnings. If you’re looking at other jobs, look over the benefits package carefully. Of course, you probably wouldn’t ask to see the benefits package during the first interview. But when offered a job, ask to review the benefits before giving your answer. Asking to review the employee benefits packages is entirely acceptable and even expected by employers. Many include it in the interview process. They usually want applicants to know their company is a good place to work. And most employers won’t mind waiting a day or so to get your answer.

Large employers usually offer the most generous benefits. They often offer not only a health care plan, life insurance, and disability insurance, but other benefits, too.

Can I get help with premiums on the Marketplace if I don’t sign up for insurance at my job?

Sometimes. If your individual insurance costs more than 9.5% of your household’s adjusted gross income, you can shop for insurance for yourself on the state exchange. If your income is low enough, you can qualify for help with premiums or other costs. If your individual coverage at work costs 9.5% or less of less of your household income, you can shop on the Marketplace but you won’t get help with premiums.

Can I shop the Marketplace if family or dependent health coverage costs too much at work?

Yes. Sometimes even though the employee’s individual coverage is affordable (if it meets the 9.5% cutoff noted above), family or dependent coverage is not. In this case, the employee can get his or her coverage at work, and shop on the Marketplace to try and get lower-cost coverage for the family. You will not be eligible for help with the premiums for family coverage, though.

What You Need To Know

  • You or spouse must be employed
  • Employees may be able to get dependent coverage to include a spouse and children until they turn 26
  • Employer may pay all or part of premium; employee’s share may be deducted from pay
  • Employee must choose a plan
  • Premium costs may be high, especially for family coverage
  • If you lost insurance or there was a status change in your family (see list), you may be allowed to sign up at times other than open enrollment.
  • Some job-based plans don’t have to meet all the requirements of the newer insurance plans (some might have caps, pre-existing condition exclusion periods, or other problems)
  • If the employer-based coverage you’re offered has very high premiums compared to your pay, you may still qualify to shop the Marketplace

 

The American Cancer Society medical and editorial content team
Our team is made up of doctors and master’s-prepared nurses with deep knowledge of cancer care as well as journalists, editors, and translators with extensive experience in medical writing.

Along with the American Cancer Society, other sources of information and support are listed below.

US Department of Labor, Employee Benefits, Security Administration (EBSA)
Toll-free number: 1-866-444-3272
Website: www.dol.gov/ebsa

    Information on employee benefit laws, including COBRA, FMLA, and HIPAA requirements of employer-based health coverage and self-insured health plans. Also has information on recent changes in health care laws. Information for military reservists who must leave their private employers for active duty can be found at: www.dol.gov/elaws/vets/userra/mainmenu.asp

State Health Care Marketplaces – US Department of Health and Human Services 
Toll-free number: 1-800-318-2596 (also in Spanish)
TTY: 1-855-889-4325
Website: www.healthcare.gov

    Provides information on the new insurance law, takes you through the steps of finding insurance, and much more. If you don’t have Internet access, the phone number will connect you with your state’s marketplace.

US Department of Health & Human Services
Website: www.healthcare.gov

    For the most up-to-date information on health care and insurance laws and how they affect you

National Association of Insurance Commissioners
Toll-free Number: 1-866-470-6242
Website: http://naic.org/state_web_map.htm

    Offers contact information for your state insurance commission. You can contact your state insurance commission for insurance information specific to your state, or report problems with your insurance company

Patient Advocate Foundation (PAF)
Toll-free number: 1- 800-532-5274
Website: www.patientadvocate.org

    Works with the patient and insurer, employer and/or creditors to resolve insurance, job retention and/or debt problems related to their diagnosis, with help from case managers, doctors, and attorneys. For cancer patients in treatment or less than 2 years out of treatment

Cancer Legal Resource Center (CLRC)
Toll-free number: 1-866-843-2572 (might need to leave a number for a call back)
Website: www.cancerlegalresources.org

    Provides free legal information about laws and resources for many cancer-related issues including health insurance issues, denial of benefits, and government benefits

*Inclusion on these lists does not imply endorsement by the American Cancer Society.

Last Medical Review: November 16, 2015 Last Revised: February 29, 2016

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