EMPLOYER-PROVIDED HEALTH INSURANCE is health insurance coverage provided to employees, and in some cases, their spouses and children, through an employer.

If you have employer-sponsored health insurance, then you have satisfied the mandate that you have health insurance. However, be sure to review and determine if the employer-sponsored health insurance gives you what you need to best manage your bleeding disorder. It is important to remember that you do not have to accept the health insurance your employer offers. But you still must have health insurance. This means you must purchase health insurance elsewhere, such as in the Marketplace. Otherwise, you can see if you qualify for Medicaid, for example. No matter what choice you make, you must have health insurance (we know, this statement for anyone with a bleeding disorder is like saying you must breathe)

It is important to weigh the coverage that the employer-sponsored health insurance provides against that available on in the Marketplace or Medicaid before declining coverage.

Some Facts:

  • Employers with 50 or more full-time equivalent (FTE) employees are required to offer their employees 鈥渁ffordable鈥 health insurance.
  • 鈥淎ffordable鈥 health insurance is health insurance where the out-of-pocket premium for employee (single) coverage does not exceed 9.5% of family income or the plan pays, on average, 60% or more of the cost of covered services.
  • If your employer has 50 or more FTE employees, offers health insurance that is NOT deemed 鈥渁ffordable,鈥 you may turn down the employer-provided coverage, and you purchase health insurance in the Marketplace, you may be eligible for premium tax credits.
  • Individuals earning between 100% and 400% of the federal poverty level (FPL) ($23,550 and $94,200, respectively, for a family of four) will have access to premium tax credits (based on income and the number of insured individuals in your family) in order to make purchasing insurance in the Marketplace more affordable.
  • Individuals earning between 100% and 250% FPL will have access to cost-sharing subsidies that will bring down their deductibles, copayments, and coinsurance.
  • If your employer has 50 or more FTE employees, offers health insurance that IS deemed 鈥渁ffordable,鈥 but you turn down the employer-provided coverage, and you purchase health insurance in the Marketplace, you will NOT be eligible for premium tax credits.

Questions to Consider:

  • What type of coverage, family, single or other, does your employer offer?
  • What is in network?
  • Are referrals needed?
  • What is the cost of it to you? (out of pocket expenses: deductibles, coinsurance, co-pays…)
  • Is your employer-sponsored health insurance plan comprehensive?
  • Does it include your health care providers?聽 Physical Therapy?
  • Does it cover clotting factor, ancillaries and other medicines you require? Does it cover factor for self infusion at home?
  • Is clotting factor covered?聽 Is it tiered?
  • Does it cover medication in the medical plan or the pharmacy plan? What are the out of pocket costs?
  • Which specialty pharmacy/home care can be used for factor delivery?
  • Will your employer-sponsored health insurance plan separately administer my benefits (e.g., your medical insurance is administered by Insurance Company A and your drug benefit is administered by Insurance Company B, even though your insurance card says one name 鈥 Insurance Company A). If so, the out-of-pocket maximums to which you may be subject for your medical and drug coverage may be impacted.
  • Will the benefits I receive from my employer-sponsored health insurance be better or worse than that offered by other health care coverage I qualify for under the ACA?
  • Will I pay more or less for my employer-sponsored health insurance than if I purchased health insurance in the Marketplace? (Subsidies and/or tax credits may be available to an employee if the employee elects to purchase health insurance in the Marketplace.)
Out of Pocket Maximums Out of Pocket Maximums. The Affordable Care Act (ACA) sets maximum limits on how much a person can be required to pay out-of-pocket annually for his or her health care: HFA Issue Brief. View now >>>
Personal Insurance Toolkit Extensive toolkit developed by the National Hemophilia Foundation (NHF) and APLUS Coalition which HFA is a part of. View now >>>
Medical Subsidy calculator With this calculator, you can enter different income levels, ages, and family sizes to get an estimate of your eligibility for subsidies and how much you could spend on health insurance. As premiums and eligibility requirements may vary, contact your state鈥檚 Medicaid office or exchange with enrollment questions. View now >>>
Medical Taxes Tax Break Can Help With Health Coverage, But There鈥檚 A Catch – Fact sheet on tax credits and subsidies View now >>> U.S. Government Site for Health Insurance information View now >>>

Learn More in a Practical Way!

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Disclaimer. This website is a resource only and should be used for information purposes. Please work with your health care providers, insurance councilors, etc. to determine the best solution for you.


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