The term “job-based coverage” includes group health insurance plans sponsored by employers or unions. Job-based health plans differ a lot and may fluctuate in response to changes in the law and economy. Understanding how your job-based health plan works and what it covers will help you maximize benefits and keep your costs down.
Who gets job-based health coverage?
Although many employers in the US 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 husband or wife. 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 ever unsure about who qualifies for a job-based group health plan, ask the employer or union directly.
Who pays what for job-based coverage?
Typically, employers, or other group health plan sponsors, pay for most of the premium, and the members contribute a portion. Most of the expenses that people 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 glossary
or ask the plan sponsor for explanations of these terms and how they apply to your coverage.
How can I keep my costs as low as possible?
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 (which many health plans now include on their websites).
Make best use of your 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 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 and any other expenditure required of an individual which is 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 are not covered by your plan.
What happens when job-based coverage ends?
Members of job-based group health plans have options for maintaining coverage even when the job or their eligibility for the plan ends, such as when the worker leaves the job, goes into Medicare, or passes away. Federal COBRA law assures that group plans with 20 or more workers offer continuation of coverage to any enrollee for a certain period (depending on the qualifying event that triggered the COBRA option), at the full expense of the individual. Or, people can buy an individual policy, which may be significantly less costly if they 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.
Who can answer questions about job-based coverage?
General information you may need about a job-based plan can be found in materials provided by your employer or plan sponsor. Ask for verification or additional details if needed. It is always a good idea to get verification of coverage details in writing. If you are unsure how to proceed, call us at 1-800-344-4867.