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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 oversees health care laws covering special medical conditions.

1. Your Options are Important

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.

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. Look for Quality

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.

4. Your Plan's Summary Plan Description (SPD) Provides a Wealth of Information

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.

5. 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.

6. 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 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.

7. HIPAA Can Also Help if You are Changing Jobs, Particularly if You Have a Medical Condition

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.

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 and the new Medicare prescription drug program.

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.

10. You Can Take Steps to Improve the Quality of the Health Care and the Health Benefits You Receive

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.

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, 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.

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