Medical Insurance at Employment

Are employers required to provide health insurance to their employees?

Maybe, depending on the employer. The Affordable Care Act (“Obamacare”) requires all businesses with 50 or more full-time employees to provide health insurance for at least 95% of their full-time employees and their dependents up to age 26 of age, or pay a fine. This health insurance, usually offered through a group plan, provides benefits for the people who belong to the group (for example, all workers at a given job site). Benefits often include payment for hospital stays, medical care, and prescription drugs. Other than the Obamacare law, employers are not required to provide health and welfare benefits to employees.

Exception: In some cities, where local governments have enacted minimum wage ordinances, if an employee works for a governmental employer or employer or an employer with a contract with the city or county, the employee may be entitled to paid health benefits by the employer, or to an increase in your hourly wage so that the employee can obtain health insurance on their own. The San Francisco Health Care Security Ordinance (“HCSO”) requires employers with at least twenty employees to pay a certain amount of money for the health care of those employees, whether paid insurance premiums, contribute to the health flexible spending account, or reimburse the health expenses of employees receiving direct medical services. To be covered by the HCSO, the employee must have worked for their employer for at least ninety days and must work in San Francisco for at least ten hours per week.

If an employer does not provide health insurance benefits or if I am working part time or unemployed, is there anything I can do to get health insurance?

Yes. There are several programs available to people without health insurance in California.

Medi-Cal is a joint (federal and state) Medicaid program that provides free or low-cost health insurance coverage. Generally, non-elderly adults with household income up to 138 percent of the Federal Poverty Level (“FLP”), pregnant women with household income up to 213 percent of the Federal Poverty Level, and Children from birth to 18 years of age with a family income up to 266 percent of the Federal Poverty Level qualify for Medi-Cal. You can also get Medi-Cal if you fall into certain categories. To see if you are eligible for Medi-Cal, contact the Department of Health Services.

The Children's Health Insurance Program (“CHIP”) can provide health insurance to children in families who do not qualify for Medicaid. Similarly, the Medi-Cal Access Program (“MCAP”) may provide health insurance for pregnant women with a family income greater than 213 percent of the Federal Poverty Level.

Covered California Health Exchange (“Covered California”) is an agency offering subsidized health insurance plans in accordance with the Affordable Care Act (also known as “Obamacare” – see above). Covered California helps individuals and families obtain health coverage that includes the minimum benefits required by Obamacare. If your household income is at or below 400 percent of the Federal Poverty Level, Covered California may qualify you for subsidized plans with reduced premiums. If your household income is between 138 percent and 250 percent of the Federal Poverty Level, Covered California may qualify you for additional discounts that lower the cost of medical services.

If my employer provides medical benefits on a voluntary basis, are there any laws that cover those benefits?

The Employee Retirement Income Security Act of 1974 (ERISA) regulates employer-provided health benefits if the employer voluntarily offers health insurance to employees. Under ERISA, employers must provide a Summary Plan Description (SPD) to employees who participate in the plan. The SPD is typically a small booklet or other type of document that explains what the plan offers and how it works, as well as providing information about when an employee can begin participating in the plan, how services and benefits are calculated, when benefits are guaranteed, when and how benefits are paid, and how to file a claim for benefits. The employer must provide the SPD to the employee free of charge within 90 days of the employee's enrollment in the plan or within 120 days of the plan's establishment. If the plan changes, the employer must notify the employee through an updated SPD or in a separate document called the Summary of Material Modifications that must be provided to the employee free of charge.

Employer-provided welfare and medical benefits are exempt from ERISA minimum participation, guarantee maturity, benefit accrual, and minimum funding requirements that apply to employer-provided retirement benefits.

If my employer provides health benefits on a voluntary basis, is it required to provide benefits to all employees?

Maybe, depending on the employer. Employers covered by Obamacare (see above) must provide health insurance for at least 95% of their full-time employees and their dependents up to age 26. Otherwise, an employer is free to cover some, rather than all, of its employees. For example, salespeople can be excluded from the health coverage plan while managers are covered.

Exception: If an employee is entitled to be enrolled in an employer-provided health benefit plan under ERISA, the employer may not improperly prevent the employee from enrolling. (For example, an employer may not deny workers health benefits based on their national origin.) To be eligible for benefits an individual must be classified as an employee, not a temporary worker or independent contractor, and must be entitled to receive benefits according to the terms of the plan.