Will I be able to stay on my employer’s insurance policy? 

If you are taking leave, it is important to read your health insurance policy and understand the coverage you have and whether you will remain covered while you are on leave. If the information isn’t in your employee manual, contact your health insurance company for a copy of your policy. It’s not an exciting read but reviewing the fine print now can reduce the likelihood of misunderstandings later. Whether you have traditional (“fee for service”) health insurance or a managed-care plan (e.g., coverage through a health-maintenance organization [HMO] or preferred-provider organization [PPO]), learn what you need to in order to get the most out of your coverage. If possible, it can also be helpful to meet with an HR staff member or an employee benefits who may be able to help answer questions.

If you are terminated because leave time runs out, or you have chosen to reduce your hours so that you are no longer eligible for benefits, consider the following:

COBRA is a federal law that applies to employers with 20 or more employees that allows you to continue the same employment-based health insurance coverage that you had while they were employed, usually for 18 or 36 months. COBRA is available to an employee or family member after an employee has terminated their employment or has reduced their work hours to a point that they are no longer eligible to receive coverage from their employer. This termination or reduction in hours is referred to as a “qualifying event.” The good news about COBRA is that you do not have to change health care providers and will maintain the same coverage you previously had. The bad news is that the coverage is no longer subsidized by the employer and you have to pay the full premium, which can be expensive. There is a program in some states called the Health Insurance Premium Payment Program (HIPP), which can help pay for an individual’s health insurance premium. In addition, some states have mini-COBRA laws that require employers with between 2 and 19 employees to offer continued coverage.

What do I do if the time period to stay on my employer’s insurance through COBRA runs out? 

First, make sure you know exactly when your COBRA coverage ends, so you can plan for it. Getting on a Health Insurance Portability and Accountability Act (HIPAA) individual plan might be an option for you. 

HIPAA, as a law, does many things, including: provides a federal right to an individual health insurance plan (called a guarantee issue plan). You must, however, meet three requirements to be eligible for a HIPAA plan: First, you must exhaust your COBRA coverage, meaning that you use all 18 or 36 months of COBRA coverage, or state COBRA coverage. Second, you cannot have a break in coverage longer than 63 days (which is why it is important to know when your COBRA coverage runs out and plan ahead when possible). Lastly, you must be ineligible for Medicare, Medicaid, or any other form of group coverage.

If you’re not able to get insurance through COBRA, and you’re not eligible for a HIPAA plan either because you did not exhaust the available COBRA coverage or if you had a break in coverage of more than 63 days, then you may be eligible for a state high risk insurance pool or a major risk plan. Some states that provide this form of high-risk medical insurance for people who are unable to obtain health insurance coverage in the individual insurance market due to a pre-existing condition. The type and availability of coverage that you receive varies depending on your state. 

As of January 1, 2014, the Patient Protection and Affordable Care Act (ACA), provides the opportunity for anyone to shop for insurance in their state’s Health Insurance Marketplace.  Health insurance companies can no longer deny selling you a policy, or charge you more, because of your pre-existing condition.  Unlike with COBRA coverage, this will be a completely new policy, so make sure that you shop carefully and pick a policy that covers your doctors, hospitals, and prescription drugs you need. Shopping for a new plan can be done immediately after your qualifying event, after your COBRA runs out, or at any other point in that time frame.  For more information about the Marketplaces, visit healthcare.gov.

What do I do if my insurance company denies coverage?

All health insurance companies must now have an internal appeals process and all states must now have an external process for consumers to appeal health insurance companies’ decisions. For example, if your insurance company denies a claim on the basis that the procedure was experimental, you now have the right, in any state, to appeal that decision and show why it was not experimental. Those enrolled in a health plan must be provided with a notice about available internal and external appeals processes and be told of the availability of assistance to help complete the process.

More information about this right can be found at https://www.healthcare.gov/marketplace-appeals/what-you-can-appeal/.

You may also want to use this Appeals Tracking Form created by Triage Cancer to keep track of where you are in the process.  If you feel that you need assistance from an attorney, you may consider contacting the National Cancer Legal Services Network (NCLSN) or LawHelp.org. 

Please note that this information is designed to provide general information on the topics presented. It is provided with the understanding that the expert is not engaged in rendering any legal or professional services in the information provided. The information provided should not be used as a substitute for professional services. Portions of the above are presented courtesy of ©Triage Cancer.

Updated 2021