What is the definition of an eligible employee for health insurance?



Employers offer affordable health insurance to employees for financial protection against medical care. Its mode of payment is designed as per the employee’s convenience. It is either the employer or worker’s organization that provides health insurance.

When employers provide health plans, they have the right to decide if they should pay part or the entire amount of health insurance premiums for employees. An employee however receives health insurance only if he is considered eligible for it.

Eligible employees are entitled to health insurance plans, and cannot be deprived of it because of previous medical conditions. Health insurance coverage is also extended to the dependents of an eligible employee.

Employer determines employee eligibility

While insurance companies set legal standards for insurance eligibility, it is the employer who determines the employee eligibility. There are no set guidelines determining health insurance eligibility; however employers follow the legally acceptable insurance standards. So employees who want to be a part of a health insurance plan in their new job, it is important to first check if he is eligible for health insurance.

Employment status of the employee while enrolling for health insurance is the most important qualification for employee eligibility. Eligible employees are those who have been employed by the employer for a year or more, and have provided at least 1,250 hours of services to the employer in a year. These hours include overtime and in case of irregular employees, he has to complete 52 working weeks to be considered eligible for health insurance.

Number of years worked

Some employers however consider employees working 30 hours or more a week a full-time employee. While full-time employees receive health insurance, it is the employer’s decision whether or not to provide part-time employees working less than 30 hours a week health insurance plans. If the employer offers health insurance to one part-time employee, it should be offered to all part-time employees too.

The total number of years an employee has worked with the employee is another criterion for determining employee eligibility. Some other eligibility qualifications are the employee’s address, how his salary is paid to him and if he has another income source.

Waiting period in health insurance

While other benefits take effect once the employee signs the application, there is a waiting period in health insurance for the provider to determine employee eligibility. It is the employer who decides on the waiting period which can be anywhere between 30 and 90 days. This waiting period applies to new hires, and once the waiting period is over, the health insurance coverage takes place.

The company’s quarterly report also verifies employee eligibility. This report is a list of the employer’s employees, and the number of over-all number of hours worked in the quarter.




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