To continue growing and attracting good employees it is essential for companies to offer its employees health coverage. Group health insurance is sold to businesses and organizations in Ohio who then provide coverage to their employees and members. These group and business health insurance plans are inexpensive compared to individual or family coverage because the cost of medical services can be spread among a larger group of people. Since the risk associated with small group health insurance is lower for the insurance company, they are also more willing to underwrite policies for those with pre-existing conditions. In fact, all small group health insurance plans are required to be guaranteed issue according to federal law.
Your protections will vary somewhat, depending on whether your plan is a fully insured group health plan or a self-insured group health plan. The plan’s benefits information must indicate whether the plan is self-insured. You have to be eligible for the group health plan. For example, your employer may not give health benefits to all employees. Or, your employer may offer an HMO plan that you cannot join because you live outside of the plan’s service area. You cannot be turned away or charged more because of your health status. Health status means your medical condition or history, genetic information or disability. This protection is called nondiscrimination. Employers may refuse or restrict coverage for other reasons (such as part time employment), as long as these are unrelated to health status and applied consistently. However, if you work for a small employer in Ohio, insurance companies must offer coverage to all eligible employees.
When you begin a new job with health insurance through an HMO, the HMO may require an affiliation period before coverage begins. During this affiliation period, you will not have health insurance coverage. An HMO affiliation period cannot exceed 2 months (3 months for late enrollees), and you cannot be charged a premium during it. If you have to take leave from your job due to illness, the birth or adoption of a child, or to care for a seriously ill family member, you may be able to keep your group health coverage for a limited time. A federal law known as a Family and Medical Leave Act (FMLA) guarantees you up to 12 weeks of job-protected leave in these circumstances. The FMLA applies to you if you work at a company with 50 or more employees.
When you first enroll in a group health plan, the employer or insurance company may ask if you have any pre-existing conditions. Or, if you make a claim during the first year of coverage, the plan may look back to see whether it was for such a condition. If so, it may try to exclude coverage for services related to that condition for a certain length of time. However, federal and state laws protect you by placing limits on these pre-existing condition exclusion periods under group health plans.
A group health plan can count as pre-existing conditions only those for which you actually received (or were recommended to receive) a diagnosis, treatment or medical advice within the 6 months immediately before you joined that plan. This period is also called the look back period. (If you are enrolling in an individual health plan or if you are self-employed, the definition of pre-existing condition is different).
Ohio has enacted reforms to expand some health insurance protections. Some of these reforms apply to groups of different sizes. Generally, small employers are those that employ 1-50 employees. Self-employed persons count as small employers in Ohio, but have somewhat different protections. Please note that the definitions of small employer and employee are somewhat different under federal and state law.
With few exceptions, small employers cannot be turned down. This is called guaranteed issue. If you employ no more than 50 people, health insurance companies must sell you any small group health plan they sell to other small employers. However, they can require that a minimum percentage of your workers participate in your group health plan. They can also require you to contribute a minimum percentage of your workers’ premiums. If you are buying a large group health plan for 51 or more employees, your group can be turned down. Your insurance cannot be canceled because someone in your group becomes sick.This is called guaranteed renewability and it applies to group plans of all sizes. Insurers can impose other conditions, however. They can require you to meet minimum participation and contribution rates in order to renew your coverage. Additionally, they can refuse to renew your coverage for nonpayment of premiums or if you commit fraud.
If you are self-employed with no other workers, you are considered to be a group of one. Insurers are required to accept your application for the standard plan or basic plan in August of each year to make coverage effective on October 1, of that year. They can refuse to sell you other plans, however. Further, the rules for pre-existing condition exclusion periods are somewhat different.
For groups of one, pregnancy can be counted as a pre-existing condition. If you are a group of one and you have had no prior coverage, the group health plan can exclude coverage for your pre-existing condition for up to 2 years. The plan can count as pre-existing any condition for which you received, or – in your insurer’s judgment, for which you should have sought – a diagnosis, treatment or medical advice in the 2 years prior to enrolling in the plan. This is called the prudent person rule. If you had prior coverage, you will receive credit toward your pre-existing condition exclusion period for any time you satisfied under your prior coverage.
