Skip to main content
Find a Lawyer
Please enter a legal issue and/or a location
Begin typing to search, use arrow keys to navigate, use enter to select

Health Insurance

Nothing compares to good preventative care when it comes to protecting your health. In this regard, health insurance is critical in safeguarding and addressing health expenses for most people.

Health insurance affects everyone, regardless of your health insurance coverage status. Maybe you don't have health coverage but wish you did after experiencing an unexpected illness or accident. You may have a health insurance plan but don't know your coverage options.

It's important to recognize that healthcare benefits and laws are ever-changing. This impacts your health insurance options. The article below discusses some of health insurance's more critical legal aspects.

How Health Insurance Works

You pay the deductible if you receive healthcare services for covered medical expenses. The insurance company then pays for specific percentages of different types of medical care. Payments are subject to policy limits, exclusions, and copays.

If you receive healthcare services for covered medical expenses, you first pay the deductible. The insurance company then pays for certain percentages of different types of medical care.

For example, the insurer may cover 80% of medically necessary surgical operations. You would then pay the other 20% until you reach your out-of-pocket maximum.

Policyholder wellness is vital to the health insurance company. The insurance company hopes to insure as many healthy people as possible. Insuring healthy people means reductions in costs, as healthy people will likely use the policy less than policyholders with health issues will.

Premiums from healthy people help cover the costs of those who are less healthy. Government-sponsored health insurance programs represent an important segment of the insurance market. Medicare and Medicaid are federal programs. Medicare provides insurance to people over 65. Medicaid provides health insurance to low-income individuals.

Open Enrollment Period

It's critical to be aware of applicable deadlines. Health insurance coverage comes with an open enrollment period. This is the case whether your coverage is through your employer, Medicare, or the Affordable Care Act (ACA) marketplace.


For ACA plans, some state-based marketplaces may have open enrollment periods. These timelines may differ from federal-based marketplaces. That's something to keep in mind.

Private Employers

Your place of employment determines the open enrollment period for your plan. Employers often have open enrollment in the fall. This timeline allows selected benefits to start at the beginning of the calendar year.

Medicare Plans

For Medicare plans, there are Medicare enrollment periods. A Medicare Advantage Plan allows you to join, switch, or drop plans during enrollment. The open enrollment period also allows you to add or drop prescription drug coverage.

Special Enrollment Periods

There are exceptions to the open enrollment period for health insurance plans. You may qualify to enroll during special enrollment periods. For example, you can only enroll or change health insurance marketplace plans if you experience certain life events. Special life events for marketplace plans can include:

  • Marriage
  • Having a baby
  • Getting divorced or legally separated
  • Death
  • Changes in residence
  • Loss of health coverage provides information on enrolling or changing plans. Private employers have similar qualifying changes. Such changes qualify you for the special enrollment period.

Am I Required To Have Health Insurance?

The Affordable Care Act originally contained an individual mandate. The mandate included a penalty for people who did not buy a health insurance plan.

This penalty was part of the legislation's effort at cost-sharing. The law required qualifying health insurance. You had to pay a fee if you didn't have insurance, subject to exemptions. It was called the individual shared responsibility payment.

The ACA sought to obtain enrollment of as many people in the healthcare market as possible. Doing so would offset the healthcare cost for people who couldn't pay, but Congress repealed the individual mandate in 2017.

ACA Subsidies

Before the ACA, Medicaid provided no subsidies or coverage for low-income working adults. Now, there are low-cost insurance options for low-income families. They include the following:

  • Direct subsidies to low-income working adults
  • Medicaid expansion that covers working adults who cannot afford health insurance
  • Premium tax credits that help lower monthly insurance premiums

Is My Employer Required To Provide Health Insurance?

Employers with at least 50 full-time employees must offer minimum essential coverage or pay a fee to the IRS. Covered employers must provide health insurance to their employees and dependents up to age 26. No federal law requires small businesses to offer health insurance for employees.

Employers and companies covered under the ACA must also abide by anti-discrimination laws. Companies must also follow laws protecting employees and plan beneficiaries. These include the following:

These laws protect employees and plan beneficiaries.

What Is the Waiting Period To Become Eligible for Coverage?

An employer cannot impose enrollment waiting periods exceeding 90 days. Shorter waiting periods are allowed, but coverage must begin no later than the 91st day after hire.

Public marketplace plans send notices to employers that may owe a penalty. Employers receive a notice when they fail to follow the employer mandate. Such notices alert employers if their employees receive a medical insurance subsidy.

What Does My Insurance Company Have To Cover?

As mentioned, health insurance laws change all the time. Insurance companies must abide by the requirements of the ACA. These include the following provisions:

  • Individuals may not be denied coverage based on pre-existing conditions, including pregnancy
  • Dependents can remain on their parent's insurance plans until they turn 26
  • Plans must cover certain preventative services for free, including shots and screening tests
  • Plans may not have lifetime or yearly dollar limits on coverage of essential health benefits
  • Companies may not cancel your health insurance because you get sick
  • Plans must also cover certain breastfeeding equipment
  • Plans must cover birth control
  • Plans must cover mental health and substance abuse services

Specific grandfathered health plans may be exempt from many ACA requirements.

Rights and Protections for Consumers

The ACA contains many provisions that would result in more affordable health insurance. Among those changes include certain rights and protections for consumers.

These protections help make healthcare coverage more fair and easier to understand. You can also learn about your medical bills and collections rights.

Get Help With Health Insurance Laws

Health insurance law can be a complicated area of law. It's normal to question how these laws affect your situation. Laws change and contain many exceptions. This can make it difficult to know your rights and responsibilities. Speak to an experienced insurance attorney today. They can help you better understand how current health insurance laws affect you.

Was this helpful?

You Don’t Have To Solve This on Your Own – Get a Lawyer’s Help

Meeting with a lawyer can help you understand your options and how to best protect your rights. Visit our attorney directory to find a lawyer near you who can help.

Or contact an attorney near you:

Next Steps

Contact a qualified attorney to assist with any issues related to insurance.

Begin typing to search, use arrow keys to navigate, use enter to select

Help Me Find a Do-It-Yourself Solution

Copied to clipboard

Find a Lawyer

More Options