If you understand your benefit options, you can better protect yourself and your family. With the basic information in hand, you can take routine steps to get the health insurance you need at every stage of your life.
Marriage
What you need to know: If you are married, you can change your health insurance by:
- Add yourself, your spouse, and your children to your employer’s plan.
- Join your spouse’s employer plan, or
- Look for insurance on the Health Insurance Marketplace.
Get detailed information about special enrollment options and be sure to understand how different plans work. Understand what benefits are covered, deductibles, copays and premiums, and whether you can continue to see the same doctors.
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What you need to do: To qualify for special coverage under the Health Insurance Portability and Accountability Act ( HIPAA ) for an employer plan, you must apply for coverage for you, your spouse, and your children within 30 days of your marriage and enroll them in your employer plan or your spouse’s employer plan. If you choose to enroll through the Marketplace, you must select a plan for you and your family within 60 days of your marriage.
You should review all of your options and compare them before deciding which health insurance plan is best for you.
Pregnancy, Childbirth and Adoption
What you need to know: Under the Affordable Care Act ( ACA ) , many employer plans and all plans purchased through the Health Insurance Marketplace must include benefits for pregnancy, childbirth, and newborn care. Most plans also cover maternity care with no copays, coinsurance, or deductibles, as long as you use an in-network health provider.
Births, adoptions, and placements for adoption may trigger special enrollment periods during which you, your spouse, and new dependents can enroll in your employer’s plan or a plan on the marketplace. Under the Newborns’ and Mothers’ Health Protection Act , plans that cover maternity or newborn benefits generally must provide coverage for hospitalization for the mother and newborn for at least 48 hours after a vaginal birth or 96 hours after a cesarean section, unless the physician or other attending physician, in consultation with the mother, decides to discharge the mother earlier. If your state has a law that provides similar protections and your plan provides coverage through an insurance policy or HMO , you may be protected by state law instead of the Newborns’ Act. Your plan must notify you of your rights to hospitalization after childbirth. If your plan is covered, the notice must list the protections provided by state law.
What you need to do: Check your plan’s Summary Plan Description ( SPD ) and Summary of Benefits and Coverage ( SBC ) to learn what maternity and newborn benefits your plan provides, as well as coverage for birth-related visits. To learn more about postpartum hospitalization in your state, visit the National Association of Insurance Commissioners website at naic.org/state_web_map.htm and find your state’s insurance commissioner’s office.
If you are applying for special enrollment for your child in your employer’s plan, you must notify the plan within 30 days of the child’s birth, adoption, or placement for adoption. Your child’s coverage begins on the date of birth, adoption, or placement for adoption. Your plan may require you to give this notice in writing.
If you choose to enroll your child through the Marketplace, you must make that choice within 60 days of your child’s birth, adoption, or adoption placement.
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If your child is no longer a dependent
What you need to know: If your employer plan offers coverage for dependent children, your children can continue to be enrolled in your plan until they are 26 years old. If your children have “aged out,” they may be eligible for:
- Covered by his/her own employer plan,
- Special eligibility for marketplace insurance, or
- Purchasing temporary health insurance for up to 36 months is permitted under the Consolidated Omnibus Budget Reconciliation Act ( COBRA ). Typically, COBRA is administered by group health plans for employers with 20 or more employees.
What you need to do: To enroll in a special marketplace plan, you must enroll within 60 days of your child’s age exceeding the plan. To elect COBRA coverage, you must notify your employer in writing within 60 days of your child turning 26. Your plan should notify your child that he or she has the right to extend his or her health benefits under COBRA . Your child will have 60 days from the date the notice is sent to make a decision to elect COBRA coverage.
Death, Legal Separation and Divorce
What you need to know: If a covered employee on an employer health plan dies, becomes legally separated, or divorces, the covered spouse and dependent children need to consider re-selecting their health insurance. If the spouse has a health plan at work, they and any dependents may be eligible for special enrollment in that plan. Alternatively, they can also special enroll in coverage on the Health Insurance Marketplace.
Spouses and dependent children are also eligible to continue their existing health insurance coverage under COBRA for up to 36 months. The plan must notify them of their right to purchase COBRA coverage. Most plans require eligible individuals to make a decision to choose COBRA coverage within 60 days of the plan’s notification .
What you need to do: To get special enrollment in health insurance, spouses and dependent children must apply for a special enrollment spouse’s employer plan within 30 days of losing coverage, or choose a plan on the marketplace within 60 days before or after losing coverage. COBRA coverage requires that if a covered employee dies, the employer must notify the plan within 30 days. If a covered employee and spouse are divorced or legally separated, they or their dependent children must notify the plan in writing within 60 days. The plan must notify spouses and dependent children of these life changes and their right to an extension of their own medical benefits. Most plans require eligible individuals to make a decision to elect COBRA within 60 days of the plan’s notification .