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The Department of Labor's Employee Benefits Security Administration
(EBSA) administers several important health benefit laws covering employer-based health plans. They govern your basic rights to information about how your health plan works, how to qualify for benefits, and how to make claims for benefits. In addition, there are specific laws protecting your right to health benefits when you lose coverage or change jobs. EBSA oversees health care laws covering special medical conditions. For more information on the laws that protect your benefits, see EBSA's Web site at
www.dol.gov/ebsa. Or, call the agency's toll-free help line at 1.866.444.3272 to reach a regional office near you. These 10 tips can help make your health benefits work better for you.
There are many different types of health benefit plans. Find out which ones
your employer offers, then check out each plan. Your
employer's human resource office, the health plan administrator, or your
union can provide information to help you match your needs and preferences
with the available plans. The more information you have, the better your
health care decisions will be.
Do the plans offered cover preventive care, well-baby care, vision or dental
care? Are there deductibles? Answers to these questions can help determine
the out-of-pocket expenses you may face. Matching your needs and those of
your family members will result in the best possible benefits. Cheapest may
not always be best. Your goal is high quality health benefits.
The quality of health care services varies, but it can be measured. You
should consider the quality of health care in deciding among the health care
plans or options available to you. Not all health plans, doctors, hospitals
and other providers give the highest quality care. Fortunately, there is
quality information you can use right now to help you compare your health
care choices. Find out how you can measure quality. Consult the U.S.
Department of Health and Human Services publication Your Guide to Choosing
Quality Health Care on the Web at www.ahrq.gov/consumer/qntool.htm.
Your health plan administrator should provide a copy. It outlines your
benefits and your legal rights under the Employee Retirement Income Security
Act (ERISA), the federal law that protects your health benefits. It should
contain information about the coverage of dependents, what services will
require a co-pay, and the circumstances under which your employer can change
or terminate a health benefits plan. Save the SPD and all other health plan
brochures and documents, along with memos or correspondence from your
employer relating to health benefits.
Marriage, divorce, childbirth or adoption, or the
death of a spouse are life events that may signal a need to change your
health benefits. You, your spouse, and dependent children may be eligible
for a special enrollment period under provisions of the Health Insurance
Portability and Accountability Act (HIPAA). Even without life-changing
events, the information provided by your employer should tell you how you
can change benefits or switch plans, if more than one plan is offered. A
special note: If your spouse's employer also offers a health benefits
package, consider coordinating both plans for maximum coverage. Read Your Health Plan and HIPAA...Making the Law Work for You.
Under the Consolidated Omnibus Budget Reconciliation Act-better known as
COBRA-you, your covered spouse, and dependent children may be eligible to
purchase extended health coverage under your employer's plan if you lose
your job, change employers, get divorced, or upon occurrence of certain
other events. Coverage can range from 18 to 36 months depending on your
situation. COBRA applies to most employers with 20 or more workers and
requires your plan to notify you of your rights. Most plans require eligible
individuals to make their COBRA election within 60 days of the plan's
notice. Be sure to follow up with your plan sponsor if you don't receive
notice and make sure you respond within the allotted time. Get the facts by
getting a copy of An Employee's Guide to Health Benefits Under COBRA.
HIPAA generally limits pre-existing condition exclusions to a maximum of 12
months (18 months for late enrollees). HIPAA also requires this maximum
period to be reduced by the length of time you had prior creditable
coverage. You should receive a certificate documenting your prior
creditable coverage from your old plan when coverage ends. To find out more,
read Questions & Answers: Recent Changes in Health Care Law.
Before you retire, find out what health benefits, if any, extend to you and
your spouse during your retirement years. Consult with your employer's human
resources office, your union, the plan administrator, and check your SPD.
Make sure there is no conflicting information among these sources about the
benefits you will receive or the circumstances under which they can change
or be eliminated. With this information in hand, you can make other
important choices, like finding out if you are eligible for Medicare and
Medigap insurance coverage and the new Medicare prescription drug program.
Understand how your plan handles grievances and where to make appeals of
the plan's decisions. Keep records and copies of correspondence. Check
your health benefits package and your SPD to determine who is responsible
for handling problems with benefit claims. Contact EBSA for customer
service assistance if you are unable to obtain a response to your
complaint.
Look for and use things like Quality Reports and Accreditation Reports
whenever you can. Quality reports may contain consumer ratings – how
satisfied consumers are with the doctors in their plan, for instance – and
clinical performance measures – how well a health care organization
prevents and treats illness. Accreditation reports provide information on
how accredited organizations meet national standards, and often include
clinical performance measures. Look for these quality measures whenever
possible. Consult Your Guide to Choosing Quality Health Care at www.ahrq.gov/consumer/qntool.htm.
The Employee Retirement Income Security Act - Offers protection for individuals enrolled in retirement, health, and other benefit plans sponsored by private-sector employers, provides rights to information, and a grievance and appeals process for participants to get benefits from their plans. The Consolidated Omnibus Budget Reconciliation Act - Contains provisions giving certain former employees, retirees, spouses, and dependent children the right to purchase temporary continuation of group health plan coverage at group rates in specific instances. The Health Insurance Portability and Accountability Act - Includes protections for millions of working Americans and their families who have preexisting medical conditions, prohibits discrimination in health care coverage, and guarantees issuance of individual policies for certain eligible individuals. The Newborns' and Mothers' Health Protection Act - Provides rules on minimum coverage for hospital lengths of stay following childbirth. Mental Health Parity Act - Requires that annual or lifetime dollar limits on mental health benefits be no lower than those dollar limits for medical and surgical benefits offered by a group health plan. Women's Health and Cancer Rights Act - Offers protections for breast cancer patients who elect breast reconstruction in connection with a mastectomy.
Call EBSA toll-free at 1.866.444.3272 for copies of the following brochures, or view them on the Internet at: www.dol.gov/ebsa.
- Your Health Plan and HIPAA...Making the Law Work for You
- An Employee's Guide to Health Benefits Under COBRA
- Retirement and Health Care Coverage...Questions and Answers for Dislocated Workers
- Can the Retiree Health Benefits Provided by Your Employer Be Cut?
Also, visit the Centers for Medicare and Medicaid Services of the Department of Health and Human Services at www.cms.hhs.gov. Or, contact your State Insurance Commissioner's Office.
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