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Fact Sheet: Life Events Impact Health Benefit Needs

Most individuals go through a number of life events that affect their      health benefit needs and the choices they make. There are several      important federal laws that affect your benefits under a job-based health      plan. Below is a list of life events and a brief description of federal      laws that may protect your rights when these events occur.

Make the Right Health Benefit Decisions When You Get Married

The Health Insurance Portability and Accountability Act (HIPAA) offers    special enrollment rights for employees and spouses that allow them to    enroll in a group health plan upon marriage and provides protections for    individuals who have preexisting conditions or might suffer discrimination    on the basis of health status when they switch plans.    

ERISA Disclosure Provisions provide individuals with rights to important    information concerning benefits under their own or spouse’s group health    plan.    

Protect Your Rights When You Have or Adopt a Baby

HIPAA prohibits preexisting condition exclusions from being applied to    pregnancy, regardless of whether the mother had previous health coverage. In    addition, HIPAA does not permit preexisting condition exclusions to be    applied to newborns and adopted children who enroll within 30 days of birth    or adoption.    

HIPAA also offers special enrollment rights for employees, spouses and new    dependents allowing them to enroll in a group health plan upon birth,    adoption, or placement for adoption.    

ERISA Claims Procedures help ensure timely and fair review of maternity and    other claims under group health plans.

The Newborns’ and Mothers’ Health Protection Act includes important new    protections for mothers and their newborn children with regard to the    lengths of hospital stays following the birth of a child.    

Keep Health Coverage After a Job Change

HIPAA protects individuals who have preexisting conditions, helping them to    keep coverage for those conditions or get coverage for them in no more than    12 or 18 months through limits on the length of preexisting condition    exclusions. HIPAA also helps individuals who might suffer discrimination in    health coverage on the basis of health status when they change jobs.

COBRA generally requires that most group health plans of employers with at    least 20 employees offer employees and their dependents the opportunity to    continue their health plan coverage for limited periods of time when the    employee loses his or her job or has a reduction in hours that would result    in a loss of coverage.

Make Sure Your Loved Ones Have Good Health Care

ERISA permits a parent to obtain a court order to provide coverage for    children under the noncustodial parent’s health plan (called a qualified medical child support    order).

ERISA Disclosure Provisions help to ensure that individuals covered by group    health plans receive clear information about their rights, benefits, and    obligations under the plan, including information about COBRA continuation    coverage, access to urgent or specialized care, and composition of physician    and other provider networks.

HIPAA includes protections for newborns and adopted children with    preexisting conditions. Specifically, HIPAA does not permit a preexisting    condition exclusion to be applied to a newborn or adopted child who enrolls    within 30 days of birth or adoption.

ERISA Claims Procedures help ensure timely and fair review of plan denials    of claims.

Keep Coverage When a Marriage Ends

HIPAA offers special enrollment rights, generally allowing employees and    dependents who were covered under a spouse’s plan to obtain coverage under    the employee’s plan upon divorce or legal separation, if they are    otherwise eligible.

COBRA generally requires that group health plans of employers with at least    20 employees offer spouses and dependent children the opportunity to    continue their health care coverage for limited periods of time in the event    of the spouse’s legal separation or divorce from the employee covered by    the plan.

Secure the Right Care in Your Later Years

HIPAA offers protections for individuals who have    preexisting conditions, helping them to keep coverage for those conditions    or get coverage in no more than 12 or 18 months through limits on    preexisting condition exclusions.    

HIPAA includes protections to help ensure individuals are    not excluded from coverage under their group health plan or charged a higher    premium based on health status.    

COBRA generally requires that group health plans of    employers with at least 20 employees offer employees and their dependents    the opportunity to continue their health plan coverage for limited periods    of time when the employee loses his or her job due to retirement.    

ERISA Claims Procedures help ensure fair and timely    appeals process for covered individuals.    

ERISA Disclosure Provisions require that group health    plan disclosure material furnished to plan participants and beneficiaries    must contain information about specialists in the plan network and the    plan’s rules for accessing specialty care.    

ERISA Disclosure Provisions also require that plan    disclosure material must describe the ability of the employer to reduce plan    benefits or terminate the plan.    

This fact sheet has been developed by the U.S. Department of Labor, Employee    Benefits Security Administration, Washington, DC 20210. It will be made    available in alternate formats upon request: Voice phone: 202.693.8664;    Text telephone: 202.501.3911. In addition, the information in    this fact sheet constitutes a small entity compliance guide for purposes of    the Small Business Regulatory Enforcement Fairness Act of 1996.
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