Frequently Asked Questions

For workers within a business (as opposed to the self-employed), there can be few factors that can determine eligibility for enrollment within the association health plan. Generally full-time employees would be eligible for plan participation if their employer is a member of an association health plan. Part-time employees may face differing premiums and/or waiting periods than full-time employees though association health plans are not obligated to make such distinctions. A waiting period is a delay between the time a worker is hired and the time when she or he may participate in an employer health plan. The maximum time an employer may extend a waiting period is 90 days.

Association health plans can also be offered to the self-employed whether they have a formally incorporated business or an unincorporated business such as tutoring or working on-demand for a ride-share service such as Uber. For more information on this group, see our article “Can the self employed, freelancers, & sole proprietors join association health plans?

As is the case for employers outside of association health plans, inside association health plans COBRA requirements apply to employers with at least 20 workers.

An association health plan must cover pre-existing conditions for any health benefit within the insurance that coincides with an Essential Health Benefit. There are 10 of these Essential Health Benefit categories:

  • Preventive Care
  • Outpatient Care (Ambulatory Services)
  • Hospital Services
  • Lab Services
  • Emergency Services
  • Medication Coverage
  • Maternity & Newborn Care
  • Mental Health Care and Substance Use Disorder Care
  • Rehabilitative & Habilitative Services
  • Pediatric Care

Any association health plan benefit corresponding to any of the above 10 categories must extend the benefit’s coverage to include health conditions that began prior to the plan participant’s enrollment. Association health plans are also prohibited from denying plan enrollment based on pre-existing conditions or adjusting premiums on the basis of a plan participant’s pre-existing conditions.

For more information, see “Association Health Insurance and Pre-Existing Conditions.”

Membership criteria depends on the association. Association membership is based on either a shared professional interest or a shared region. This shared trait among association members is known as the association’s “commonality of interest.” More information on commonality of interest can be found in our article on how to start an association.

Association membership is open to employers, including self-employed individuals (e.g. freelancers, contractors, sole proprietors, part-time workers, etc.) if the association chooses to extend them membership. These members are known as “working owners.” Working owners are simultaneously an employer member of an association and also an employee that is a participant within the association health plan.

Within an association health plan, multiple employers (including the self-employed) may band together to sponsor medical coverage. By leveraging the total number of employees across all the employers within the association, the association can:

· Access the more flexible “large group” health plan regulatory environment, which can allow health plans to adapt health plan benefits to employee needs and expense considerations

· Negotiate better rates with insurers than might be obtained through traditional small group or individual health insurance coverage

An association must be “bona fide” in order to offer a health plan. A bona fide association involves considerations around association, membership criteria, association control, plan participation, and nondiscrimination.

For a more detailed discussion of the eight requirements for bona fide association health plans, see our article “bona fide associations.”

Yes, the new association health insurance regulation does allow freelancers, sole proprietors, and the self-employed to participate in association health plans. Individuals belonging to these groups would be considered “working owners.” For more information on working owners, see our article “What is a working owner?

In most states, 51 total employees aggregated across all employers belonging to an association is sufficient to qualify for large group status. Typically, these employees need to be eligible for the health plan to meet the 51-employee threshold. However, in four states, there is a larger employee requirement. California, Colorado, New York, and Vermont all require 101 total employees to qualify for large group health plan status.

Yes. Association health plans are regulated at the federal and state level. Consequently, there are a variety of benefit requirements that apply to them, although they are less extensive than the benefit requirements for Affordable Care Act health plans.

For a broader discussion of benefit requirements for association health plans and under what conditions they apply, read “association health plan benefit requirements.”

No. Association health plans, whether fully-insured or self-insured multiple employer welfare arrangements (MEWAs), will continue to operate under existing state oversight.

No. Existing association health plans may continue to operate under the previous regulatory guidance if they so choose. However, they do have the option to operate according to the new regulation.