In the US, a majority of people under the age of 65 obtain health insurance coverage through employer-sponsored group health plans either from their own job or through a family member's employer. Group health benefits are voluntarily provided as there is no federal law that currently requires employers to offer coverage or to contribute a minimum amount towards an employee's premium. However, it is possible that some other requirement, for example, a collective bargaining agreement between your union and your employer, obligates the employer to offer health benefits.
Employers that offer health insurance benefits finance those benefits in one of two ways: they purchase health insurance from an insurance company (fully-insured plans), or they provide health benefits directly to employees and assume the financial risk (self-insured plans). Federal law protections for consumers in employer-sponsored group health plans apply whether the group health plan is fully-insured or self-insured. Additional state protections apply only to fully-insured group health plans.
The American Diabetes Association has worked to pass health insurance provisions in 46 states that require fully-insured health plans — those regulated by state governments — to provide coverage for diabetes medications, supplies, and services. These laws do not apply to policies that self-insure.
If you are self-employed or lose your employer-sponsored coverage, please refer to our insurance information sheet for individuals to learn about coverage options.
A federal law known as the Employee Retirement Income Security Act (ERISA) sets rules for private employer-sponsored benefit plans, including health insurance plans. ERISA protections for people in job-based health plans include:
- You generally cannot be turned away or charged a higher premium because of your health status under an employer-sponsored plan.
- Employer-based plans are currently allowed to exclude coverage for pre-existing conditions for a period of time, usually no more than for one year. If you had other coverage without a significant break before joining your current plan, generally it must be credited toward the pre-existing condition exclusion period. Due to the health reform law, starting in September 2010, job-based health plans won't be allowed to deny or exclude coverage to any child under age 19 based on a pre-existing condition.
- With group plans, there is a yearly open enrollment period where you can change coverage. If you experience a change in family status (such as marriage or the birth or adoption of a child) or lose other coverage, a 30-day "special enrollment" opportunity outside of open enrollment must be offered to you.
- There must be written rules for how you file a claim and how you can appeal a denial of covered services. Federal law requires the claims appeal process to be fair and timely.
- Group plans sponsored by employers with 20 or more workers generally must offer you the chance to temporarily continue coverage after you are laid off, quit, retire or lose dependent status under the plan, but you will be required to pay for this coverage.
Check with your employer to find out whether group coverage is available in your workplace. If health insurance coverage is available and you choose to take it, you should receive a written plan summary explaining what will be covered under your health plan and what rules you must follow under the plan. Be sure to find out what diabetes supplies and services are included in your health plan.
For more information on employer-sponsored health coverage and to find out what type of coverage laws exist in your state, please contact the office of your state insurance commissioner. Contact information for state insurance departments is available at: www.naic.org/state_web_map.htm. More information about job-based coverage is also available at: www.healthcare.gov/using-insurance/understanding/options/.
The Affordable Care Act, the federal health reform law enacted in March 2010, provides new protections and improves access to affordable coverage options. The reforms will not be implemented all at once but rather in stages. In addition, whether various portions of the Affordable Care Act apply to your policy will depend upon whether your employer is fully insured or self insured and whether your employer retained the same policy as existed when health reform was passed (known as grandfathered plans). Portions of the law have already taken effect while other regulations will be implemented through 2014 and beyond. These new provisions include:
- A new federal government health care web portal was created which includes a tool that allows you to search for insurance options. This is available at: finder.healthcare.gov
Starting as early as September 2010:
- Job-based health plans and new individual plans won't be allowed to deny or exclude coverage to any child under age 19 based on a pre-existing condition, such as diabetes.
- If you have children under age 26, you can generally insure them if your policy includes coverage for dependents. The only exception is if you have a "grandfathered" employer-based plan and your adult child has an offer of health insurance through his/her job.
- Insurance companies cannot include lifetime limits on coverage and annual limits in most plans are restricted and later phased out.
Beginning in 2014:
- Employer-based health plans and new individual plans won’t be allowed to exclude anyone from coverage or charge a higher premium for a pre-existing condition, such as diabetes.
- If your employer does not offer insurance or that insurance isn't affordable, you will be able to buy insurance directly through an Exchange in your state. An Exchange will be a new marketplace where individuals and small businesses can buy affordable health insurance that meet certain benefits and cost standards.
- If your income is less than the equivalent of 400% of the poverty level (which was about $43,000 for a single individual or $88,000 for a family of four in 2010) and your job does not offer affordable coverage, you will be able to get tax credits to help you pay for insurance.
For more information on your rights and protections as a health insurance consumer, please visit: www.healthcare.gov/using-insurance/understanding/rights/
For information about managing your health insurance, please visit: www.healthcare.gov/using-insurance/managing/
The American Diabetes Association will provide updated information as it pertains to people with diabetes on our website as the reforms go into effect. However for the most up-to-date information, please refer to the new health care web portal at: www.healthcare.gov. Additionally, for a timeline of what is changing and when, please refer to: www.healthcare.gov/law/timeline/.
Some information on this fact sheet is from www.healthcare.gov and "Health Insurance Resource Manual," prepared for American Diabetes Association by Georgetown University Health Policy Institute.
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