The federal and state rules employers must follow when offering benefits: ERISA, COBRA, SBCs, Form 5500, ACA reporting, HIPAA, and more.
Yes. Almost every employer covered by the Fair Labor Standards Act must give each employee a written notice about the Health Insurance Marketplace and their coverage options. New hires must get it at the time of hiring (within 14 days, per DOL), whether or not they enroll.
Not by itself. Offering MEC to at least 95% of full-time employees avoids the larger no-offer penalty, but a bare MEC plan that is unaffordable or lacks minimum value can still trigger the smaller penalty when an employee gets a subsidized Marketplace plan.
A participatory program rewards you just for taking part, like a gym reimbursement; a health-contingent program ties the reward to meeting a health standard and must follow extra rules, including a reward cap and a reasonable alternative.
Ask your plan for its medical-necessity criteria, the reason for any denial, and its comparative analysis of treatment limits. If they show stricter rules for mental health care, you can appeal and file a complaint with the U.S. Department of Labor.
For most people, yes. Marketplace and other individual and small-group plans must cover mental health and substance use treatment as an essential health benefit; large-employer plans usually do but are not required to.
If your plan covers out-of-network medical care, parity requires it to cover out-of-network mental health and substance use care on comparable terms. It does not force a plan with no out-of-network medical benefits to add them.
Businesses under common ownership can be treated as a single employer. For the ACA, all employees of a commonly owned group are combined to test the 50 full-time-equivalent threshold for ALE status, though each company stays its own ALE member for penalties and reporting.
It depends on the leave. Under FMLA (employers with 50+ employees), coverage must continue on the same terms. For non-FMLA leave, it’s governed by the employer’s written policy and the carrier’s eligibility rules.
HIPAA guarantees that employees moving between group plans can’t be denied coverage for health reasons, and it gives special-enrollment rights when someone loses other coverage or gains a dependent.
Coverage must be maintained during FMLA leave, but the employee still owes their share. The employer sets a payment arrangement; if the employee doesn’t pay within the grace period, coverage can be dropped after proper notice, and the employer may recoup advanced premiums on return.
In Texas, an eligible dependent who loses group coverage due to divorce can generally continue it for up to nine months under state continuation when federal COBRA doesn’t apply. Verify current Texas rules at enrollment.
Five jurisdictions enforce a penalty: California, Massachusetts, New Jersey, Rhode Island, and Washington, D.C. Vermont has a mandate with a reporting requirement but no penalty. Everywhere else, only the (currently $0) federal rule applies.
All three report health coverage for taxes. 1095-A comes from the ACA marketplace (needed to reconcile subsidies), 1095-B comes from insurers/small plans showing you had coverage, and 1095-C comes from large employers (50+) documenting their offer of coverage.
There’s no federal penalty; the ACA individual-mandate penalty has been $0 since 2019. But a handful of states impose their own penalty if you go without coverage.
The SBC presents every plan’s costs and covered services in the same standardized format; deductible, out-of-pocket max, what’s covered, and sample cost examples, so consumers can compare plans apples-to-apples.
HIPAA’s Privacy and Security Rules limit how a health plan and its vendors can use or share protected health information, require safeguards, and give individuals rights to access their own records.
ERISA is the federal law governing most private-sector employee benefit plans. It sets rules for plan documents, employee disclosures (like the SPD), fiduciary duties, claims and appeals, and reporting (Form 5500).
Yes. An employer may require, or the employee may choose; that accrued paid leave (like PTO or sick time) run at the same time as unpaid FMLA leave, under the employer’s normal leave rules.
Yes. An employee returning from FMLA leave must be restored to the same group health coverage on the same terms as before, with no new waiting period or re-qualification.
Yes. Under the federal FMLA, an employer must maintain the employee’s group health coverage during job-protected leave on the same terms as if they were still working.
Hawaii’s Prepaid Health Care Act requires employers to cover employees working 20+ hours a week, pay at least half the premium, and cap the employee’s share at 1.5% of wages; stricter than federal rules.
The Women’s Health and Cancer Rights Act requires group and individual plans that cover mastectomies to also cover breast reconstruction, prostheses, and treatment of related complications such as lymphedema. Plans must notify members of these rights yearly.
Group health plans must give employees several required notices, including the Summary of Benefits and Coverage (SBC), SPD, CHIP notice, Marketplace (Exchange) notice, Medicare Part D creditable-coverage notice, WHCRA notice, and applicable COBRA notices.
The Marketplace Notice is a short notice that virtually all employers must give every new hire (within 14 days of starting) explaining that health coverage is available through the ACA Marketplace and how the employer’s plan affects subsidy eligibility.
No. Under the Medicare Secondary Payer rules, an employer with 20 or more employees cannot require, pressure, or financially incentivize a Medicare-eligible active employee to drop the group plan in favor of Medicare. Doing so can trigger a civil money penalty of $11,823 per violation in 2026.