Frequently Asked Questions on Health Insurance:
- When do employers have to offer health insurance benefits to their employees and or their dependents?
- Can I find out about a prospective employer's health benefits before I take a job?
- Can I be excluded or dropped from my group health plan due to my MS?
- What is a pre-existing condition? Does taking medication qualify as "treatment"?
- The enrollment form for my new employer’s health plan has a question asking if I have ever been treated for a whole list of conditions, including MS. I don’t want my new employer to know about my MS. What happens if I do not disclose it?
- How long can I keep my group health benefits under COBRA?
- I did not continue my health benefits under COBRA when I left my job a few weeks ago because I couldn't afford it. But now my parents are offering to help me out by paying the COBRA premiums. Can I still get the group health benefits?
- I have been covered by my husband's group health plan through his job, but now we are getting divorced. What will happen to my health benefits?
- Can I enroll in both my own employer's plan and my spouse's plan? Is it worth the extra cost I would have to pay in premiums? What about our dependent children?
- My teenager has MS and is insured by my husband’s employer. What will happen to his coverage when he goes to college? What if he puts off college until he is 19 or older?
- My employer just informed us that to save money, the company is cutting out some benefits from our health coverage, including prescription drugs. Can they do that?
- What happens to my group health benefits when I become eligible for Medicare?
- What types of services or treatments do health plans commonly deny or limit to people with MS? What can the National MS Society do to help?
- My health plan just informed me that it will no longer be including one of my drugs on their formulary. What exactly are formularies? What can I do?
When do employers have to offer health insurance benefits to their employees and or their dependents?
At present, employers are not required to offer health coverage as a benefit to their employees and/or their dependents. Although most employers currently do offer health plan enrollment as an optional benefit, (usually to their full time employees only), the percentage of them that do is declining every year. Employers who offer coverage in a health plan usually pass some of the premium costs on to eligible employees who choose to enroll. When employers offer health benefits, the employer determines the benefit package and eligibility requirements for employees and/or their dependents. For example, an employer is free to provide benefits only to full time employees who have successfully passed a probationary period of employment for six months.
Can I find out about a prospective employer's health benefits before I take a job?
Yes, and you should. These days, health coverage is an important consideration for almost everyone, and inquiring about health benefits is normal whether or not a job applicant has a chronic health concern. Ask if there is any information about the health plan you can see in writing before you make a commitment. Try to be casual about your questions, and suggest that you want to compare the plan's benefits with those of your current plan or other options for coverage open to you. Check the list of excluded benefits in particular. Keep in mind that an employer cannot base a job offer to you on the knowledge or even perception of a disability.
Can I be excluded or dropped from my group health plan due to my MS?
No. If you, your spouse and/or dependent(s) are eligible for group health benefits from an employer, a federal law known as HIPAA (The Health Insurance Portability and Accountability Act of 1996) guarantees that no individual can be singled out and excluded from the group health plan due to their health status or history. The same law also guarantees that an individual eligible for group health benefits cannot be charged more in premiums due to a medical condition, or given fewer benefits.
What is a pre-existing condition? Does taking medication qualify as "treatment"?
Federal law defines a pre-existing condition as either a physical or mental condition, regardless of the cause, for which medical advice, diagnosis, care or treatment were recommended or received within the six month period ending on the date of enrollment in a new plan. The legal definition is intentionally broad in scope to include virtually anything for which an individual saw or consulted with a health professional, or received treatment. "Treatment" includes any type of therapy, diagnostic test, consultation, or medication.
The enrollment form for my new employer’s health plan has a question asking if I have ever been treated for a whole list of conditions, including MS. I don’t want my new employer to know about my MS. What happens if I do not disclose it?
Failure to disclose information about your medical history or preexisting condition if or when asked by a health plan is considered fraud -- a serious offense which can lead to the loss and future ineligibility of coverage for you and your dependents. The consequences of not disclosing this information if or when asked is simply not worth that risk. If you are concerned about your employer finding out about your MS from this form, you should know that you and your dependents are well covered by a variety of legal protections. You may want to read up on your employment rights, as well as ways HIPAA protects your medical privacy.
How long can I keep my group health benefits under COBRA?
Under normal circumstances, a qualified employee leaves employment can "elect coverage" under COBRA to continue in their company’s health plan for up to 18 months, provided they pay the full premium, and payment is received on time. For COBRA qualifying events affecting a spouse or dependent children, such as separation, divorce, death or children leaving the plan due to age, the election period is up to 36 months. Individuals determined to be disabled by the Social Security Administration may extend their group benefits to 29 months if the Social Security administration determines that their disability date (first day the disability began) occurred within the first 60 days of their COBRA coverage.
I did not continue my health benefits under COBRA when I left my job a few weeks ago because I couldn't afford it. But now my parents are offering to help me out by paying the COBRA premiums. Can I still get the group health benefits?
That depends on how long you waited after your former employer offered the COBRA coverage. Anyone eligible for COBRA continuation of benefits has only 60 days to elect their COBRA benefits.
I have been covered by my husband's group health plan through his job, but now we are getting divorced. What will happen to my health benefits?
A divorce is a qualifying event under COBRA law, so you are eligible for a continuation of benefits under the law. Separated or divorced spouses are eligible for continued benefits for up to 36 months provided the premium (and 2% administrative fee) is paid. You will want to review plans for COBRA payments, as well as any future plan's premiums, in your divorce negotiation.
Can I enroll in both my own employer's plan and my spouse's plan? Is it worth the extra cost I would have to pay in premiums? What about our dependent children?
Spouses and dependent children may enroll in more than one plan, but the coordination of benefits, (COB, or sequence of plans to which claims will be submitted) must be indicated at the time of enrollment. The basic advantage of multiple coverage is the possibility of reimbursement for any portions of a covered medical service or item remaining for you to pay yourself. For example, if (after your annual deductible is met) you get reimbursed by Insurer A approximately 70% of a medical bill you have already paid, you can submit a claim for reimbursement to Insurer B for the remaining 30% of the bill. Of course, only claims for covered benefits qualify for reimbursement, and pre-paid health plans that do not use claim forms would not qualify.
Check with your benefits administrator or coverage manual for information describing their rules for coordinating benefits and payment of premiums. Generally, the plan covering the individual as an employee pays first and the plan covering the individual as a dependent pays second. If both plans cover the individual as dependent child, there is a 'birthday rule'—the plan of the employee whose birthday occurs earliest in the year pays first.
My teenager has MS and is insured by my husband’s employer. What will happen to his coverage when he goes to college? What if he puts off college until he is 19 or older?
If your health plan covers your dependent children, you should examine your manual to know exactly when your child is no longer covered. This may occur at a specific age, or when he or she enrolls in a student health plan, or when your child moves away from home. Your child with MS will be protected under the provisions of COBRA and HIPAA if he or she has been covered under a group health plan in the past. If you were planning or assuming that a student health plan would cover your child's health care during his school enrollment, be very careful. Ask questions about the school's health plan in advance and examine the provisions of the policy to see what it offers. You may want to extend your child's coverage under COBRA instead. Also, make sure you ask if the student plan would be considered "creditable coverage" under the provisions of HIPAA. If not, your child may find him/herself joining a group health policy of a future employer and then learn that his/her MS is deemed ineligible for coverage for the first 12 months because it is considered a "pre-existing condition."
My employer just informed us that to save money, the company is cutting out some benefits from our health coverage, including prescription drugs. Can they do that?
Yes, as long as the benefits are the same for all eligible plan enrollees. Employers may offer eligible employees a selection of health plans, such as a lower-cost HMO that limits enrollees to network doctors and providers only, or a higher cost plan that allows for a wider range of providers. Besides these basic differences, however, HIPAA assures that all plan enrollees are guaranteed access to the same health benefits.
What happens to my group health benefits when I become eligible for Medicare?
Generally, individuals become eligible to enroll in Medicare when they reach age 65, or are disabled and have been receiving Social Security Disability Income (SSDI) checks for 24 months, or have a diagnosis or either end-stage renal disease or ALS (Lou Gehrig’s Disease). While the law allows people to maintain their group health coverage and coordinate it with Medicare, anyone covered by a group plan who is planning on enrolling in Medicare should check their group plan's eligibility rules to find out their plan’s rules regarding Medicare enrollment, and to determine which insurance is primary (pays first), and which is secondary. Watch the relevant dates carefully, and beware that eligible individuals only have 80 days to enroll in Medicare Part B after their group health benefits end, or face paying a higher Part B premium as penalty.
What types of services or treatments do health plans commonly deny or limit to people with MS? What can the National MS Society do to help?
National MS Society staff often hears from people with MS about disputes over coverage of specific drugs, rehabilitation therapy (including physical, occupational, speech or cognitive therapy), wheelchairs and scooters, and other durable medical equipment. The Society produces Expert Opinion Papers and other reports describing the appropriate role and value of certain therapies in the diagnosis and management of MS. Feel free to provide these to your insurance policy administrators and/or your personal physician. In addition, the Society offers health care professionals Health Insurance Appeal Letters: A Toolkit for Clinicians that includes citations to research studies supporting the appropriateness and medical necessity of specific treatments for you and your MS provider.
My health plan just informed me that it will no longer be including one of my drugs on their formulary. What exactly are formularies? What can I do?
A formulary is a list of specific prescription drugs that the plan has approved for its enrollees. Any drug that is on the formulary is approved by the plan and the cost of the medication will be covered, although there will be co-payments and deductibles. Formularies have become increasingly common cost and quality control strategies in health plans that include prescription drug coverage. Some plans strictly limit their coverage to drugs on the plan's formulary alone, and others provide partial coverage for "non-formulary" drugs.
Plans usually include their drug formularies with the information new plan enrollees receive about their plan, and update it periodically. Keep this list with your other health plan information, or ask for it specifically if or when the need arises.
If you receive a notice that a drug your doctor has prescribed is not on the formulary or it is being taken off the formulary, show him or her the letter and review your options. Would your doctor be comfortable prescribing a drug that is on the formulary instead? If not, ask him to write your insurer a letter explaining why it is important for you to get the original drug he/she originally prescribed. If your doctor believes it is important for you to get the drug he/she originally prescribed, the National MS Society may be able to help your doctor advocate with your insurance plan on your behalf.