Who is an Eligible Employee?

Health insurance is offered by employers to their employees for financial protection pertaining to medical care. It is often made affordable and has a mode of payment designed for the employees’ convenience. Health insurance is normally established by either the employer or a worker’s organization. Since an employer is not obliged to provide health insurance plan to their employees, a worker’s organization can legally do so. But when an employer provides health plans, it is their discretion whether to pay just part or the entire amount of the health insurance premiums for their employees.

In an employment setting, health insurance coverage can only be availed of if a worker is considered an eligible employee. An eligible employee is by law entitled to a health insurance plan and he can’t in any way be deprived of it based on his previous medical conditions. Insurance companies may set standards in order for the employee to be considered eligible provided that none of their qualifications violate the law. But in most cases, it is the employer who determines the employee eligibility. Although it doesn’t follow that all employers must exactly have the same guidelines to determine employee eligibility for health insurance purposes, but they do commonly adhere to the insurance standards which are legally acceptable. Whenever a person gets a job, of course one of his main concerns is the benefits that he can avail of especially health insurance benefits. And in order to enroll and be a part of the health insurance group plan in a company, a worker must first check if he is an eligible employee.

The primary qualification for employee eligibility is the employment status of the employee at the time of enrollment of the health insurance. Generally speaking, a person is considered an eligible employee if he has been employed by the employer for one year or more and has rendered at least 1,250 hours of service for the employer during the one year period. The 1,250 working hours includes overtime rendered and if the employee is irregular or has an intermittent work, he is required to complete 52 working weeks. But some employers consider a worker a full-time employee if the service rendered by the employee per week is 30 hours or more. Full-time workers are particularly offered health plans and if the company offers health coverage to one of its full-time employees, it must offer the same to all employees. However for part-time employees (those employees rendering less than 30 hours) it is the employer’s prerogative whether or not to offer health insurance plans. But when an employer provides a health plan to a part-time employee, it must also do so to all part-time employees.

Tenure or the total number of years an employee has been working with the employer is also one of the basis in determining employee eligibility. Some other qualifications are based on where an employee lives or if he has other source of income and how his salary is being paid to him by the employer. Other benefits normally take effect after the employee signs the application, but in health insurance plans, there is a waiting period which determines employee eligibility. An employer often selects the waiting period.

A waiting period is the length of time that runs from the first day that the employee starts working up to 30 or 90 days. For example, in a 90 days waiting period, if you start working on January 25, health insurance will commence on May 1, which is the first day of the month after the 90 working days. It’s only after the waiting period that the health insurance coverage will take effect. This waiting period applies to new hires only. The health insurance coverage can also be extended to the dependents of an eligible employee.

Health insurance companies also verify employee eligibility by means of the company’s quarterly report. Typically, an Insurance company can request copies of quarterly wage report from the employer. The wage report comprises the complete list of the workers employed in the company and the over-all number of hours worked in that quarter.