The Department of Labor’s Employee Benefits Security Administration ( EBSA ) administers several important health care benefits laws that cover employer-based health care plans. These laws include:
- The basic right to know about health care plans,
- How to qualify and apply for benefits,
- The right to continue receiving health care benefits if you lose insurance or change jobs, and
- Protection against special medical conditions.
Here are 10 tips to make the most of your health care benefits.
1. Explore your health insurance options
There are many different health care benefit plans. Find out what plans your employer offers and then review them. Your employer’s human resources office, health plan administrator, or union can provide this information and help you match your needs and preferences with available plans. Or choose a health plan through the Health Insurance Marketplace. Visit HealthCare.gov to learn about the health plan options available in your area. Get information about all of your options and review them. The more information you have, the better your health care decisions will be.
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2. Check available benefits
Determine your needs and priorities. Does the employer-provided plan cover mental health services, baby care, vision or dental care, or other benefits that are important to you? Is there a deductible? What out-of-pocket expenses might be? Compare all of your options before deciding which insurance to choose. Matching your needs and those of your family will result in the best benefits. The cheapest isn’t always the best option. Your goal should be high-quality, affordable health benefits.
3. Read your Summary Plan Description ( SPD ) and understand the wealth of information it provides
The Summary Plan Statement outlines your benefits and legal rights under the Employee Retirement Income Security Act ( ERISA ), a federal law that protects your health care benefits. It should also include information about dependent coverage, which services require copayments or coinsurance, and under what circumstances your employer can change or end a health benefit plan. In addition to the Summary Plan Statement, there is also a Summary of Benefits and Coverage (SBC), which is a short, easy-to-understand summary of the plan’s coverage and costs. Your health plan administrator should provide copies of both documents with your enrollment materials. Keep the Summary Plan Statement, SBC, and all other health plan handbooks and documents, as well as memoranda or correspondence from your employer regarding your health benefits.
4. Use your health insurance
Once you have health insurance coverage, you can use it to help pay for health services, such as doctor visits, prescription drugs, or emergency medical treatment. Using your benefits can help you and your family stay healthy and lower your health care costs. The Affordable Care Act ( ACA ) protects people who are enrolled in employment-based health plans, including prohibitions on denying coverage for pre-existing conditions and annual and lifetime spending limits on essential health benefits. Also, many plans cover certain preventive services at no charge, including routine vaccinations, well-baby and child checkups, blood pressure, diabetes and cholesterol testing, and screening for many cancers. You can also keep your children on your health plan until they turn 26. Take advantage of your benefits, especially if your plan includes free preventive care. If you have to pay a cost-sharing fee for preventive services, check your Explanation of Benefits and make sure the provider is charging you correctly for the services.
5. Understand your plan’s mental health and substance abuse disorder coverage
Many health plans cover mental health and substance abuse disorder benefits. If a plan offers these benefits, the financial requirements (such as copayments and deductibles) and quantitative treatment restrictions (such as visit limits) for these benefits cannot be more restrictive than those that apply to medical/surgical benefits. Plans also cannot impose lifetime and annual spending limits on the amount of mental health services, including behavioral health treatment, and substance abuse disorder services. Some plans include preventive services, such as free screening for depression and behavioral evaluations for children. Please review your Plan Summary Description and Summary of Benefits and Coverage to find out what your plan covers.
6. Check out your physical and mental health options
More and more employers are creating wellness programs to encourage employees to exercise, quit smoking, and generally adopt a healthier lifestyle. The Health Insurance Portability and Accountability Act ( HIPAA ) and the ACA encourage group health plans to adopt wellness programs, but also prohibit discrimination against employees and their dependents based on health factors. These programs often offer incentives, such as reduced fees and health promotion. Check your Plan Summary Description and Summary of Benefits and Coverage to find out if your plan offers wellness programs. If your plan has such a program, find out what incentives are offered and how to get them.
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7. Learn how to appeal if your medical benefit claim is denied
Understand your plan’s procedures for filing benefit claims and appealing plan decisions. Be aware of time limits and make sure you file your claims and appeals promptly so that the plan administrator can make decisions on time. Keep records and copies of all correspondence. Check your health benefit file and your Summary Statement of Plan to determine who is responsible for processing benefit claim issues. If the plan administrator does not respond to your complaint, contact EBSA for help.
8. Evaluate your health insurance coverage as your family’s circumstances change
You may need to change your health insurance after certain life events, such as marriage, divorce, childbirth, adoption, death of a spouse, or because the children age out of your parents’ health plan. You, your spouse, and your dependent children may qualify for health insurance from another employer or for special enrollment through the Health Insurance Marketplace. Even if there is no life-changing event, the information provided by your employer should tell you how to change benefits or switch plans. If you are considering special enrollment, act quickly. You have 30 days after a life event to request special enrollment for another employer’s 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 insurance coverage
If you change employers or lose your job, you may need to find other health insurance. If you find a new job, consider joining your new employer’s plan. Whether you start a job or lose a job, you may be eligible for special coverage through a plan sponsored by your spouse’s employer or through the Health Insurance Marketplace. Under the Consolidated Omnibus Budget Reconciliation Act, or COBRA , you, your covered spouse, and your dependent children may be eligible to maintain coverage under your previous employer-sponsored plan. This coverage is temporary (generally 18 to 36 months), and you may have to pay the full premium plus a 2% administrative fee. Get information about your coverage options and compare them. Know the deadlines for deciding coverage and find out when your new coverage will take effect.
10. Retirement Planning
Before you retire, you should know what health benefits, if any, you and your spouse will receive. Check with your employer’s human resources office, the union, or the plan administrator. Review the Summary Plan Description and other plan documents. Make sure there are no conflicting information in these documents about the benefits you will receive or when they can be changed or eliminated. With this information, you can make other important choices, such as deciding whether to enroll in Medicare or purchase Medigap , if you qualify. If you want to retire before you qualify for Medicare and your employer does not offer retirement health benefits, consider how to get health insurance. Your options may include enrolling in your spouse’s employer health plan or a plan on the health marketplace, or temporarily continuing your employer coverage by electing COBRA . Retirement planning includes planning for health insurance in retirement. To learn more, read Taking the Mystery Out of Retirement Planning (see back).
These laws will help
- Employee Retirement Income Security Act – Provides protections for individuals who participate in retirement, health, and other benefit plans sponsored by private sector employers and provides participants with rights to know and to make claims and appeals to obtain benefits from their plans.
- Patient Protection and Affordable Care Act – Provides protections for employment-based health insurance, including expanding coverage for dependent children to age 26, prohibiting exclusions for pre-existing conditions, and prohibiting lifetime and annual limits on essential health benefits. It also created the Health Insurance Marketplace.
- Consolidated Omnibus Budget Reconciliation Act – Provides some former employees, retirees, spouses, and dependent children with the right to temporarily continue coverage under a group health plan at the group rate under certain circumstances.
- Health Insurance Portability and Accountability Act – Allows employees, their spouses, and their dependents to enroll in employer-provided health insurance, regardless of open enrollment period, in the event of loss of coverage, marriage, birth, adoption, or in the process of adoption. Also prohibits discrimination in health insurance.
- Women ‘s Health and Cancer Rights Act – Provides protections for breast cancer patients who choose breast reconstruction following a mastectomy.
- Newborns ‘ and Mothers’ Health Protection Act – provides minimum coverage for hospital stays after childbirth.
- Genetic Information Nondiscrimination Act – prohibits group health insurance plan premium discrimination based on genetic information. In addition, group health insurance plans are generally prohibited from requiring genetic information or requiring genetic testing.
- The Mental Health Parity and Addiction Equity Act and the Mental Health Parity Act – require that mental health and substance abuse benefits have the same financial requirements and treatment limitations as medical and surgical benefits.
- 21st Century Cures Act – Promotes better understanding and compliance with the Mental Health Parity and Addiction Equity Act ( MHPAEA ) , including improved disclosure and compliance assistance. The Cures Act also clarifies that benefits for eating disorders are covered by the MHPAEA.
- Children ‘s Health Insurance Program Reauthorization Act – Allows special enrollment in group health insurance plans if an employee or dependent loses CHIP or Medicaid coverage or qualifies for premium assistance under those programs.
- No Surprises Act – Limits additional out-of-pocket costs (surprise bills) for out-of-network emergency services received at in-network facilities, non-emergency services from out-of-network providers, and air ambulance services under certain circumstances.