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Eligible Employees and Dependents
 Employee Eligibility
Eligibility of Spouses and Children
Eligibility of Domestic Partners
The general rule is that if an employer offers group health coverage to any full-time employees, the employer must offer coverage to all full-time employees (defined as those working 30 or more hours per week).
As for part-time employees (defined as those working 20 to 29 hours per week), the employer has the option of whether to offer coverage to them. If the employer offers coverage to any part-time employees, all of them must be offered the coverage.
These rules apply regardless of the medical condition of the employees. In other words, any eligible employee can't be denied coverage based on previous medical problems, otherwise known as pre-existing conditions.
In addition, any dependents of eligible employees are also generally eligible for coverage under a group plan. Dependents include spouses, children, and in some cases, unmarried domestic partners. Dependents cannot enroll for coverage unless the employee has enrolled.
Below are more details regarding who can receive coverage under your business's group plan.
Employee Eligibility
An employer can cover any employee who is on its payroll and for whom it pays payroll taxes. Although employees can opt out of the benefit program, virtually all insurers do require that a minimum number of your employees participate in their plan.
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See "Participation Requirements" in the tool box for more information. |
Eligible employees generally include those who are on paid vacation, maternity or sick leave. With few exceptions, employees who are on unpaid leave are ineligible until they return to active work.
The following individuals are usually not eligible for small group medical coverage:
- Employees covered under a collective bargaining agreement
- Employees of unrelated organizations
- Independent contractors
- Non-employee directors of the company
- Retirees
- Seasonal employees
- Temporary employees
Eligibility of Spouses and Children
Generally, coverage must be offered to an employee's legal spouse and dependent children. Each insurer defines "children" differently; some more broadly, some more narrowly. Check the evidence of coverage (EOC) booklet that you get from your insurer (or ask your agent or broker if you have one) to clarify definitions. In the meantime, the general rule is that insurance covers dependent children up to age 19.
If an employee's child is in school full-time, the coverage age limits usually go up. Insurance generally covers full-time students up to age 23, but age limits vary by plan.
Eligibility of Domestic Partners
Employers may opt to extend health benefits to unmarried domestic partners of employees. If an employer chooses to offer coverage to domestic partners, the coverage must mirror those for spouses.
Domestic partners can include:
- Same sex,
- Opposite sex, or
- Both same sex and opposite sex partners.
Employees and their domestic partners must sign an affidavit of domestic partnership to establish that they are living together in a committed relationship, and intend to stay that way indefinitely. The purpose of the affidavit is to deter roommates or others who simply share living space from defrauding the insurer.
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In the tool box, you can download a blank "Affidavit of Domestic Partnership" form. |
The choice to extend coverage usually depends on financial, cultural and social factors. Keep in mind that there may be incentives for employers to extend coverage to domestic partners. For example, the City and County of San Francisco requires any potential contractor businesses to offer domestic partner coverage to their employees. The City and County of San Francisco's Human Rights Commission can offer more information about domestic partner coverage within San Francisco.
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See "Advocacy Organizations" in the tool box for contact information for the San Francisco Human Rights Commission. |
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