Legal Dictionary: Employer Health Benefits

A written certificate issued by a group health plan or health insurance issuer that shows your prior health coverage.

COBRA provides rights to temporary continuation of group health plan coverage for certain employees, retirees, and family members. It does so at group rates when coverage is lost due to certain qualifying events. Learn more at FindLaw's page How Does COBRA Insurance Work?

An individual who is provided coverage under a group health plan subject to COBRA because that individual was employed by one or more persons maintaining the group health plan.

Prior health coverage you have had in the past. This includes coverage under a group health plan, an HMO, an individual health insurance policy, or Medicare or Medicaid. This prior coverage was not interrupted by a significant break in coverage.

A list of all the medicines that will be covered by your group health plan.

When referring to health coverage, this means to choose, generally in writing, to participate in a group health plan.

Written notification that you are eligible for COBRA continuation coverage. This notice should explain how long you have to elect COBRA continuation coverage. The election notice should explain how much you must pay for coverage and when and to whom the payments are due.

A collective group or union formed by employees to advocate for their interests in the workplace. These organizations may negotiate with employers to secure favorable health benefits packages for their members. An employee organization can also be an employee beneficiary association.

ERISA is a federal law that establishes standards for pension retirement benefits and health plans offered by private employers. It sets guidelines for plan administration, disclosure, and fiduciary responsibilities. Learn more via FindLaw's What is ERISA? article.

The first day of coverage or, if there is a waiting period, the first day of the waiting period. If you enroll when first eligible for coverage, your enrollment date is often the first day of employment. If you enroll as a late enrollee, your enrollment date is the first day of coverage.

This means your COBRA continuation coverage has ended. This may be because the period that this coverage was available to you has lapsed. Additional reasons for the exhaustion of COBRA coverage are possible besides the time being up. You may have exhausted your coverage because your employer failed to pay the premiums on time. Another reason may be that you no longer live or work in an HMO service area and there is no similar COBRA coverage available to you.

The FLSA sets minimum wage, overtime pay, record-keeping, and youth employment standards for employees. The FLSA also indirectly impacts employer health benefits by establishing certain standards for employee compensation and working conditions.

An employee benefit plan established or maintained by an employer, an employee organization (such as a union), or both. The plan provides medical care to employees and their dependents directly or through insurance reimbursement.

A legal entity consisting of participating medical providers that provide or arrange for care to be furnished to a given population group. HMOs are used as alternatives to traditional indemnity plans.

An individual who enrolls in a group health plan on a date after the earliest date on which coverage can begin under the plan terms or on a special enrollment date.

The Newborns' Act is a federal law that prohibits group health plans, insurance companies, and HMOs from restricting a mother's or newborn's benefits for hospital stays to less than 48 hours following a vaginal delivery or 96 hours following delivery by cesarean section. The attending doctor, nurse, midwife, or other licensed healthcare provider can discharge earlier after consultation with the mother.

The person who is responsible for the management of the plan for the benefit of participants and beneficiaries. The plan administrator is a person designated by the terms of the plan. If the plan does not make such a designation, then the plan sponsor is often the plan administrator.

The plan sponsor is the employer, the employee organization (such as a union), or both, that establishes or maintains a plan, including a group health plan.

An illness or condition that was present before an individual's first day of coverage under a group health plan. Health insurers are now prohibited from charging higher rates or refusing coverage based on pre-existing health conditions. As a result, they cannot impose benefit limits for these conditions.

Qualified beneficiaries include covered employees, their spouses, and their dependent children who are covered under the group health plan on the day before a qualifying event. In certain cases, retired employees, their spouses, and dependent children may be qualified beneficiaries. Any child born to, or placed for adoption with, a covered employee during a period of COBRA continuation coverage is a qualified beneficiary.

A specific life event that triggers a special enrollment period. This allows individuals to make changes to their health insurance coverage outside of the regular open enrollment period. Examples of qualifying events include marriage, birth or adoption of a child, loss of other health coverage, or a change in residence that affects eligibility for coverage.

A significant break in coverage is 63 consecutive days during which you have no creditable coverage. In some states, the period is longer if your plan coverage is provided through an insurance policy or HMO. Days in a waiting period during which you had no other health coverage cannot be counted toward determining a significant break in coverage.

The group of covered employees, their spouses, or dependent children who are covered under a group health plan maintained by the employer or employee organization. This group is receiving their benefits under the group plan and not through COBRA continuation coverage. They are situated to the circumstances of the qualified beneficiary immediately before the qualifying event.

An important document that the plan administrator must provide to participants and beneficiaries. It explains what coverage the plan offers, how the plan operates, and the rights and responsibilities of participants and beneficiaries. Each SPD is different. If you need a copy of the SPD, contact your plan administrator.

Special enrollment is the opportunity to enroll in a group health plan when certain work or life events occur, regardless of the plan's regular enrollment dates. If certain conditions are met, special enrollment is available when:

• You, your spouse, or your dependents lose other coverage
• When you marry
• When you have a new child by birth, adoption, or placement for adoption

The period that must pass before an employee or dependent is eligible to enroll under the terms of the group health plan. Days in a waiting period are not counted toward creditable coverage unless there is other creditable coverage during that time. Days in a waiting period are also not counted when determining a significant break in coverage.

WHCRA is a federal law that provides important protections for individuals who have undergone a mastectomy.