Fact Sheet: Workers’ Right To Health Plan Information
The Employee Retirement Income Security Act (ERISA) governs approximately 2.5 million health benefit plans sponsored by private sector employers nationwide. These plans provide a wide range of medical, surgical, hospital and other health care benefits to some 137 million Americans.
Under ERISA, workers and their families are entitled to receive a summary plan description (SPD). The SPD is the primary document that gives information about the plan, what benefits are available under the plan, the rights of participant and beneficiaries under the plan, and how the plan works.
Among other information, the SPD of health plans must describe:
The SPD must also explain how plan benefits may be obtained and the process for appealing denied benefits.
ERISA also requires that SPDs be updated periodically. Furthermore, ERISA requires disclosure of any material reduction in covered services or benefits to participants and beneficiaries generally within 60 days of the adoption of the change through either a revised SPD or a summary of material modification (SMM). Material changes that do not result in a reduction in covered services or benefits must be disclosed through an SMM or revised SPD not later than 210 days after the end of the plan year in which the change was adopted.
The Department’s claims procedure regulation describes your right to get an answer from your health plan regarding your health benefit claim. The regulation protects you – providing for a timely response by describing the timeframes for a decision, providing for a fair process by describing the standards for a decision, and providing for meaningful disclosure by describing the notice and disclosure that you are entitled to receive from your plan. Look to the SPD for information on your health plan’s claims procedure.
This fact sheet has been developed by the U.S. Department of Labor, Employee Benefits Security Administration, Washington, DC 20210. It will be made available in alternate formats upon request: Voice phone: 202.693.8664; TTY: 1.202.501.3911. In addition, the information in this fact sheet constitutes a small entity compliance guide for purposes of the Small Business Regulatory Enforcement Fairness Act of 1996.