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There are many different types of health benefit plans. Find out which one
your employer offers, then check out the plan, or plans, offered. 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.
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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.
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The quality of health care services varies, but quality 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 internet.
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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.
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Marriage, divorce, child birth 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.
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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 Health Benefits Under the Consolidated Omnibus Budget
Reconciliation Act.
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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.
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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.
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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.
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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. Consult Your Guide to
Choosing Quality Health Care on the internet.
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