Employers offer many types of medical plans. These can include preferred-provider organizations, point-of-service plans, health-maintenance organizations or indemnity plans. During an open enrollment period, employees have the chance to swap plans or change the parameters of current plans. It's also important to note that plans can change what they cost and cover each year, advises the U.S. Department of Health and Human Services. Choosing a plan can be complicated, but there are some simple rules that govern open enrollment.
Accepting Applicants Required
Insurance carriers must accept all applicants of the group during the open enrollment period, which is usually held once a year. The insurer must do this without underwriting or evidence of insurability, according to the National Association of Insurance Commissioners. Employees who miss open enrollment often are not able to enroll in their employer-sponsored health programs until the next open enrollment period. Also, employees are not able to make changes in their health care plans until the next open enrollment period. There are exceptions to this, such as when an employee is new or has a life-changing event, including a job change, divorce, marriage, and birth or adoption.
Pre-Existing Conditions
Under the Health Insurance Portability and Accountability Act of 1996, an insurer can only look back six months for a condition that existed prior to the start of coverage in a group health plan, according to the U.S. Department of Labor. That means a pre-existing condition exclusion only may be imposed if medical diagnosis, advice or treatment was received or recommended during the six months before a person's enrollment date in a plan. For example, a person who has suffered arthritis for 10 years before taking a new job but does not have any medical care, advice or diagnoses in the six months before enrolling in the new plan cannot be subject to a pre-existing condition exclusion. If the person had care during the six-month window, the plan may impose a pre-existing condition exclusion for treating the arthritis. HIPAA also prohibits plans from using pre-existing condition exclusions for genetic information and pregnancy.
Provide a Guide
Companies that offer open enrollment also need to provide an open enrollment guide. The guide details all of the options employees have. For example, plan materials need to tell employees which hospitals, physicians, labs, pharmacies and other medical facilities are in-network or out-of-network. The guides also detail the amounts the insurance carrier will pay under each plan type.
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