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Top 10 Ways to Make Your Health Benefits Work for You

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Top 10 Ways to Make Your Health Benefits Work for You.  To order copies call 1-866-444-3272.

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 website 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 your 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 preexisting 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 or 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. To find out more, read Taking the Mystery Out of Retirement Planning.

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, visit the Agency for Healthcare Research and Quality at the U.S. Department of Health and Human Services.

Note: The Affordable Care Act (ACA) adds important protections related to employment based group health plans that will improve health coverage for you and your family. Many of these protections are available now including extending dependent coverage until age 26, prohibiting preexisting condition exclusions for children under 19, and banning lifetime limits on coverage for essential health benefits. Additional protections will be available in 2014. This publication does not reflect the provisions of the Affordable Care Act. For more information, visit the Employee Benefits Security Administration’s ACA web page at www.dol.gov/ebsa/healthreform.

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 Women's Health and Cancer Rights Act offers protections for breast cancer patients who elect breast reconstruction in connection with a mastectomy.
  • The Newborns' and Mothers' Health Protection Act provides rules on minimum coverage for hospital lengths of stay following childbirth.
  • The Genetic Information Nondiscrimination Act prohibits discrimination in group health plan premiums based on genetic information. Also, generally prohibits group health plans from requesting genetic information or requiring genetic tests.
  • The Mental Health Parity and Addiction Equity Act and the Mental Health Parity Act prohibits lifetime or annual limits on mental health/substance use disorder benefits that are lower than lifetime or annual dollar limits on medical/surgical benefits. Requires parity in financial requirements and treatment limitations for mental health/substance use benefits with those for medical/surgical benefits.
  • The Children's Health Insurance Program Reauthorization Act allows special enrollment in a group health plan if an employee or dependents lose coverage under CHIP or Medicaid or are eligible for premium assistance under those programs.

To Find Out More…

Visit the Employee Benefits Security Administration’s website at www.dol.gov/ebsa to view the following publications. To order copies or to request assistance from a benefits advisor, contact EBSA electronically at www.askebsa.dol.gov or call toll free 1.866.444.3272.

Also, visit the Centers for Medicare and Medicaid Services of the Department of Health and Human Services. Or, contact your State Insurance Commissioner's Office.