6.2 Washington Group Health Insurance & COBRA

Continuation of Group Health Coverage

When group health coverage would otherwise end, COBRA (Consolidated Omnibus Budget Reconciliation Act) lets a qualified beneficiary keep the same plan temporarily by paying the full premium themselves. The exam tests the size threshold, durations, and premium caps precisely.

Federal COBRA Basics

COBRA Durations by Qualifying Event

Trap: Unlike many states, Washington does NOT impose a broad small-employer health "mini-COBRA" mandate. Continuation for groups under 20 depends on the carrier's policy/contract terms and certain leave laws — do not assume an automatic 18-month state continuation for tiny employers. Washington's protections focus instead on guaranteed issue and renewal, below.

Qualifying Events and Qualified Beneficiaries

A qualifying event is the loss of coverage trigger; a qualified beneficiary is the covered employee, spouse, or dependent child who may elect continuation. The same event produces different durations depending on who it affects:

Notice timing matters: the employer must notify the plan within 30 days of a termination, death, or Medicare event, while the employee or beneficiary must notify the plan within 60 days of a divorce or a child's loss of dependent status. Missing the beneficiary-notice window can forfeit COBRA rights — a frequently tested administrative trap.

Washington Small Group Health Insurance

Washington defines the small group market as 1-50 employees. Under the Affordable Care Act (ACA) as enforced by the Office of the Insurance Commissioner, these protections apply:

Guaranteed Issue and Renewal

• Guaranteed issue: the carrier must accept every eligible small employer regardless of the group's health or claims history.
• No pre-existing-condition exclusions are permitted.
• Community rating: premiums vary only by allowed factors (age within a 3:1 band, geographic area, tobacco use, family size) — not by health status or gender.

A small group plan must be guaranteed renewable and may be non-renewed only for:

Mental Health and Substance Use Parity

Washington and the federal Mental Health Parity and Addiction Equity Act (MHPAEA) require that behavioral health benefits be no more restrictive than medical/surgical benefits:

HIPAA Portability and Creditable Coverage

The Health Insurance Portability and Accountability Act (HIPAA) protects workers changing jobs. Key portability facts:

• A certificate of creditable coverage documents prior continuous coverage.
• Prior coverage credits against any new-plan limitations (the ACA has since eliminated most pre-existing exclusions for compliant plans).
• A 63-day break in coverage breaks the chain of creditable coverage.

Worked Example

A 12-employee Seattle firm is too small for federal COBRA. When an employee leaves, COBRA is not mandated; the worker instead may buy individual coverage through Washington Healthplanfinder — loss of job-based coverage is a qualifying event triggering a special enrollment period.

Required Group Health Benefits in Washington

Washington layers state benefit mandates on top of the ACA's essential health benefits. Producers should know that compliant Washington group and individual plans must cover:

• Preventive services at no cost-sharing (immunizations, screenings).
• Maternity and newborn care, including a minimum hospital stay of 48 hours after a vaginal delivery and 96 hours after a cesarean.
• Behavioral health under the parity rules above.
• Prescription drugs, with a formulary and an appeals process.
• Dependent coverage to age 26, regardless of marital or student status.

Coordination of Benefits (COB)

When a person is covered by two group plans, coordination of benefits prevents paying more than 100% of the actual expense. The plan covering the person as an employee (rather than as a dependent) is generally primary. For children of married parents, the birthday rule makes the plan of the parent whose birthday falls earlier in the calendar year the primary payer.