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

Top 10 Ways to Make Your Health Benefits Work for You

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 also oversees health care laws covering special medical conditions. For more information on the laws that protect your benefits, see EBSA's Website. Or call the agency toll free 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. Explore Your Options for Health Coverage

You have options for health coverage. There are many different types of health benefit plans. Find out what your employer offers, then check out the plan (or plans). 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. Or consider a health plan through the Health Insurance Marketplace. Visit HealthCare.gov to see the health plan options available in your area. Get information about all of your options and review it. The more information you have, the better your health care decisions will be.

2. Review the Benefits Available

Do the plans offered cover the benefits that are important to you, such as mental health services, well-baby care, vision or dental care? Are there deductibles? What are the out-of-pocket expenses you may face? Determine your needs and priorities. Compare all of your options before you decide which coverage to elect. 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 also should contain information about the coverage of dependents, what services will require a co-payment or coinsurance, and the circumstances under which your employer can change or terminate a health benefits plan. You also can find many of the answers to your questions in the Summary of Benefits and Coverage (SBC), a short, easy-to-understand summary of what a plan covers and what it costs. You should receive a copy with your enrollment materials. Save the SPD, the SBC, and all other health plan brochures and documents, along with memos or correspondence from your employer relating to health benefits.

4. Use Your Health Coverage

Once your health coverage has started, use it to help cover medical costs for services like going to the doctor, filling prescriptions or getting emergency care. Using your benefits will help you and your family stay healthy and reduce your health care costs. The Patient Protection and Affordable Care Act (ACA) provides many valuable protections for people enrolled in employment-based health plans including prohibiting preexisting condition exclusions and annual and lifetime limits on essential health benefits. What’s more, many plans cover certain preventive services for free, including routine vaccinations, regular well-baby and well-child visits, blood pressure, diabetes and cholesterol tests, and many cancer screenings. You also can keep your children on your health plan until age 26. Take advantage of your benefits, especially free preventive care if your plan covers it. If you were required to pay cost-sharing for a preventive service, check your Explanation of Benefits and ensure that the provider billed the service properly.

5. Understand Your Plan’s Mental Health and Substance Use Coverage

Many health plans provide coverage for mental health and substance use disorder benefits. If a plan does offer these benefits, the financial requirements (such as co-payments and deductibles) and the quantitative treatment limits (such as visit limits) for the mental health and substance use disorder benefits cannot be more restrictive than the financial requirements or treatment limits applied to medical/surgical benefits. Plans also cannot impose lifetime and annual limits on the dollar amount of mental health and substance use disorder services, including behavioral health treatment. Some plans cover preventive services like screenings for depression and child behavioral assessments for free. Check your SPD and SBC to find out what your plan covers.

6. Look For Wellness Programs

More employers are establishing wellness programs that encourage employees to work out, stop smoking, and generally adopt healthier lifestyles. The Health Insurance Portability and Accountability Act (HIPAA) and the ACA encourage 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. Check your SPD and SBC to see whether your plan offers a wellness program(s). If your plan does, find out what reward is offered and what you need to do to receive it.

7. Know How to File an Appeal if Your Health Benefits Claim is Denied

Understand your plan’s procedures for filing a claim for benefits and where to make appeals of the plan's decisions. Pay attention to time limits – make sure you timely file claims and appeals and that the plan makes decisions on time. 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 assistance if you are unable to obtain a response to your complaint.

8. Assess Your Benefits Coverage as Your Family Status Changes

Marriage, divorce, childbirth or adoption, the death of a spouse, and aging out of a parent’s health plan are life events that may signal a need to change your health benefits. You, your spouse, and your dependent children may be eligible for special enrollment into other employer health coverage or through the Health Insurance Marketplace. Even without life-changing events, the information provided by your employer should tell you how you can change benefits or switch plans. If you’re considering special enrollment, act quickly. You have 30 days after the life event to request special enrollment in other employer coverage or 60 days to select a plan in the Marketplace.

9. Be Aware that Changing Jobs and Other Work Events Can Affect Your Health Benefits

If you change employers or lose your job, you may need to find other health coverage. If you have a new job, consider enrolling in your new employer’s plan. Whether starting or losing a job, you may be eligible to special enroll in a spouse’s employer-sponsored plan or through the Health Insurance Marketplace. Under the Consolidated Omnibus Budget Reconciliation Act – better known as COBRA – you, your covered spouse, and your dependent children may be eligible to continue coverage under your former employer-sponsored plan. This coverage is temporary (generally 18 to 36 months) and you may have to pay the entire premium plus a 2 percent administrative charge. Get information on your coverage options and compare. Be aware of the deadlines for deciding on coverage and find out when your new coverage will be effective.

10. 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. Check your SPD and other plan documents. 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. If you want to retire before you are eligible for Medicare and your employer does not provide health benefits in retirement, consider what you will do for health coverage. Your options may include enrolling in a spouse’s employer plan or in a Marketplace plan or temporarily continuing your employer coverage by electing COBRA. Planning for retirement includes planning for your health coverage in retirement. To find out more, read Taking the Mystery Out of Retirement Planning.

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 claims and appeals process for participants to get benefits from their plans.
  • The Patient Protection and Affordable Care Act – Creates the Health Insurance Marketplace and provides protections for employment-based health coverage, including extending dependent coverage of children to age 26; prohibiting preexisting condition exclusions and prohibiting lifetime and annual limits on essential health benefits.
  • 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 – Allows employees, their spouses and their dependents to enroll in employer-provided health coverage regardless of open enrollment periods if they lose coverage or in the event of marriage, birth, adoption or placement for adoption. Also prohibits discrimination in health care coverage.
  • 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 – Requires parity in financial requirements and treatment limitations for mental health and substance use benefits with those for medical and 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.

For More Information

Visit the Employee Benefits Security Administration’s Website to view the following publications. To order copies or to request assistance from a benefits advisor, contact EBSA electronically or call toll free 1-866-444-3272.

You also may visit the U.S. Department of Health and Human Services Website at HealthCare.gov or call 1-800-318-2596. This is where you can find out more about Marketplace plans, what they cover, and how to apply. You also can get information by contacting your state insurance commissioner’s office.