The Department of Employee Benefits Safety (EBSA) at the State Employment Service oversees important benefit legislation for health plans offered by employers. These rules include:
- Your basic right to be informed about how your health plan works
- How to qualify and apply for benefits
- Your right to continue health benefits if you lose your insurance or change jobs and
- Protection in the event of specific medical conditions.
These 10 tips will help you make your health benefits work for you.
Find out about all your health insurance options
There are many different types of health benefit plans. Find out what plan your employer offers, then check and compare your options. Your employer’s Human Resources (HR) department, Affordable health care plan administrator or trade union can provide more information to help you match your needs and preferences with available plans. Or, consider a health plan available through the Health Insurance Marketplace TM (Marketplace) .
Find out about the benefits available
Define your needs and priorities. Do the plans you offer include benefits that are important to you, such as mental health, childcare, vision, or dental care? Are there any restrictions? What expenses do you have to reckon with? Before choosing a specific plan, you should compare all available options. Matching your and your family’s needs with the plans you offer will bring the best possible benefits. Remember that cheap isn’t always the best. Your goal should be high-quality health services that are affordable for you.
Review your Summary Plan Description to see all the information your plan contains
The Summary Plan Description (SPD) sets out your benefits and your rights under the Employee Pension Protection Act or ( ERISA ), the federal law that protects your health benefits. The SPD should also include information on insurance for your dependents, which services require additional expenses, and the dates on which an employer may change or terminate health benefits. In addition to the SPD, the Summary of Benefits and Coverage (SBC) is a short, easy-to-understand document that provides information on coverage and pricing. Your health plan administrator should provide a copy of both documents along with the recruitment materials.Keep the SPD, SBC, and all other health plan brochures and documents, along with notes or correspondence from your employer regarding health benefits.
Take advantage of health insurance
Once your health insurance period starts, use it to pay for medical expenses for services such as visiting a doctor, filling your prescriptions or getting emergency care. Using benefits will help you and your family stay healthy and lower your healthcare costs. The Affordable Care Act (ACA)protects those covered by employer-provided health plans, including the exclusion of pre-existing medical conditions and the annual and lifetime limits on basic health benefits. Moreover, many plans include some preventive services for free, including routine immunization; regular visits to the health of the baby and the health of the baby; blood pressure, diabetes and cholesterol tests; and a lot of cancer screening. Each health plan allows your children to be insured until the age of 26. Enjoy your benefits, especially free preventive care, if your plan covers it. If the service requires additional fees – check the SBC and make sure that the provider has correctly charged the service fee.
Check your plan for mental health benefits and substance abuse
Many health plans cover mental health and substance use disorders. If your plan offers these benefits, the additional fees and benefit limitations (such as visit limits, etc.) for those benefits must not be more restrictive than those that apply to medical / surgical benefits. The plans also cannot impose lifetime or annual limits on the amount of mental health benefits and substance use disorders, including behavioral treatments. Some plans include free prevention services, such as screening for depression and assessing children’s behavior. Check the SPD and SBCto find out what your plan includes.
Check health promotion programs
An increasing number of employers are developing health promotion programs that encourage workers to exercise, quit smoking, and a healthier lifestyle in general. The Health Insurance Portability and Accountabiliy Act (HIPAA) and the ACA are committed to group health plans adopting health promotion programs. But at the same time, it prohibits discrimination against workers and their dependents on the basis of health. Often these programs reward participants with lower insurance costs and generally promote a healthy lifestyle. Check the SPD or SBCto make sure your plan includes health promotion programs. If so, find out what conditions you must meet to receive the benefits of these programs.
Learn how to appeal if your claim for health benefits is denied
Review your plan ‘s procedures for claiming benefits and appealing plan decisions. Pay attention to deadlines – make sure you file claims and appeals in a timely manner and the plan makes decisions on time. Keep records and keep copies of all correspondence. Check your health benefits package and SPD to determine who is responsible for resolving issues with your benefits claims. Contact EBSA for assistance if the plan does not respond to your complaint.
Your health insurance in the event of a change in family status
If there are certain life events , such as marriage, divorce, childbirth or adoption, the death of a spouse, or your child reaching the age of 26, your health plan may need to be changed. If you change jobs, you, your spouse and your dependent children may qualify for health coverage offered by your spouse’s employer or for health benefits through the Marketplace . Even without life-changing events, the information provided by your employer should show you how you can change your benefits or change your plan.If you are considering other plans, act quickly. You have 30 days after your life event to request a special registration with another employer insurance or 60 days to choose a plan on the Marketplace .
Remember that changing jobs and other work related events can have an impact on your health insurance
If you change employer or lose your job , you may need to find another health insurance. If you find a new job, check the health plans your new employer is offering. Regardless of starting or losing your job, you may qualify for a special health plan sponsored by your spouse’s employer or through the Marketplace . In accordance with the Consolidated Omnibus Budget Reconciliation Act (COBRA), You, your spouse and your dependent children may qualify for continued coverage under a previous employer sponsored plan. This coverage is temporary (typically 18 to 36 months) and you may have to pay the entire premium plus 2 percent of the administration fee. Get information on any options and compare. Find out about the deadlines for making your insurance decisions and find out when the new insurance will take effect.
Before you retire , find out the health benefits it will have for you and your spouse. Consult your employer’s human resources department, trade union, or plan administrator. Check the SPD and other plan documents. Make sure these sources do not contain conflicting information about the benefits you will receive or the circumstances in which they may change or be suspended. With all the information in hand, you can make other important choices, such as deciding whether to enroll in Medicare or take out Medigap (if you qualify). Before you qualify for Medicare, check that your current employer provides health benefits while you wait for Medicare . If not, think about how you will get health insurance for this period? Your options may include enrolling in your spouse’s employer’s plan, a plan on the Marketplace , or temporarily continuing your employer coverage by selecting COBRA . Planning for retirement includes planning your health insurance. For more information, see Taking the Mystery Out of Retirement Planning (back page).
- Employee Retirement Income Security Act – Provides protection for people covered by private sector employer-sponsored retirement, health and other benefit plans, and gives participants rights to information, and the claim and appeal process for benefits .
- Patient Protection and Affordable Care Act – Provides employment-based health coverage, including the extension of child dependent insurance to age 26, a ban on exclusion of pre-existing conditions, and a ban on lifetime and annual limits on basic benefits health. It also created a Marketplace .
- Consolidated Omnibus Budget Reconciliation Act – gives certain former employees, pensioners, spouses and dependent children the right to purchase temporary continuation group insurance in certain cases at group rates.
- Health Insurance Portability and Accountability Act – allows employees, their spouses and their dependents to join the health insurance provided by the employer, regardless of open enrollment periods in the event of loss of insurance or in the event of marriage, birth, adoption or transfer to adoption. It also prohibits discrimination in healthcare.
- The Women’s Health and Cancer Rights Act – provides protection for breast cancer patients who choose to undergo breast reconstruction in connection with a mastectomy.
- The Newborns ‘and Mothers’ Health Protection Act – provides minimal postpartum hospital coverage.
- Genetic Information Nondiscrimination Act – prohibits discrimination in contributions to a group health plan based on genetic information. In addition, it generally forbids group health plans to request genetic information or request genetic testing.
- The Mental Health Parity and Addiction Equity Act and Mental Health Parity Act – requires that financial requirements and treatment limitations for mental health services and psychoactive substance use be equal with those of the Mental Health Parity and Addiction Equity Act and Mental Health Parity Act . which concern medical and surgical services.
- The 21st Century Cures Act – promotes better understanding and compliance with the MHPAEA Act , including more effective diagnosis and compliance support. The Cure Act also explains that the eating disorder benefits are covered by MHPAEA .
- Children’s Health Insurance Program Reauthorization Act – allows special enrollment in a group health plan if an employee or dependents lose coverage under the Children’s Health Insurance Program ( CHIP ) and Medicaid or qualify to specific assistance under these programs.
- The No Surprises Act – limits excessive own additional expenses for receiving care outside the network of emergency services and non-emergency services, from providers who know beyond the list of authorized health care providers in certain circumstances, and in cases where it is necessary to use an ambulance by air.