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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.
1. Realize that Your Options are Important
There are many different types of health benefit plans.
Find out which one your employer offers, then check out the plan, or
plans, offered. 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. If your employer
offers a high deductible health plan, look into setting up a Health
Savings Account to save money for future medical expenses on a tax-free
basis. The more information you have, the better your health care
decisions will be.
2. Review the Benefits Available
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.
3. Read Your Plan's Summary Plan Description (SPD)
for the Wealth of Information It Provides
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.
4. Assess Your Benefit Coverage as Your Family
Status Changes
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.
5. Be Aware that Changing Jobs and Other Life Events
Can Affect Your Health Benefits
Under the Consolidated Omnibus Budget Reconciliation
Act-better known as COBRA-you, your covered spouse and your 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).
6. Remember to Consider HIPAA If You are Changing
Jobs
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 Your Health Plan and HIPAA…Making
the Law Work for You).
7. Look For Wellness Programs
More and more employers are establishing wellness
programs that encourage employees to work out, stop smoking, and generally
adopt healthier lifestyles. HIPAA encourages group health plans to adopt
wellness programs but also includes protections for employees and
dependents from impermissible discrimination based on a health factor.
These programs often provide rewards such as cost savings as well as
promoting good health. To find out more, read Your Health Plan and
HIPAA ... Making the Law Work for You).
8. Plan For Retirement
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.
9. Know How to File an Appeal if Your Health
Benefits Claim is Denied
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. Also, read Filing a Claim for Your Health
or Disability Benefits).
10. Take Steps to Improve the Quality of the Health
Care and Health Benefits You Receive
Consider the quality of health care in deciding among
the health plans or options available to you. The quality of health care
services varies but it can be measured. Look for quality reports that
contain consumer ratings and clinical performance measures and check to
see that accredited organizations meet national standards. To 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.
These laws can help:
-
The Employee Retirement Income
Security Act - Offers protection for individuals enrolled in
retirement, health, and other benefit plans sponsored by
private-sector employers, and 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.
To find out more...
Call EBSA toll-free at 1.866.444.EBSA (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 [View]
An Employees's Guide to Health Benefits Under COBRA [View]
Filing a Claim for Your Health or Disability Benefits [View]
Retirement and Health Care Coverage...Questions and Answers for Dislocated Workers [View]
Can the Retiree Health Benefits Provided by Your Employer Be Cut? [View]
Life Changes Require Health Choices...Know Your Benefit Options [View]
Work Changes Require Health Choices...Protect Your Rights [View]
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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