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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 131 million Americans.
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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.
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Among other information, the SPD of health plans must
describe:
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Cost-sharing provisions, including
premiums, deductibles, coinsurance and copayment amounts for which the
participant or beneficiary will be responsible
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Annual or lifetime caps or other
limits on benefits under the plan
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The extent to which preventive
services are covered under the plan
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Whether, and under what
circumstances, existing and new drugs are covered under the plan
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Whether, and under what
circumstances, coverage is provided for medical tests, devices and
procedures
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Provisions governing the use of
network providers, the composition of provider networks and whether,
and under what circumstances, coverage is provided for out-of-network
services
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Conditions or limits on the
selection of primary care providers or providers of specialty medical
care
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Conditions or limits applicable to
obtaining emergency medical care
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Provisions requiring
preauthorizations or utilization review as a condition to obtaining a
benefit or service under the plan
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The SPD must also explain how plan benefits may be obtained and the process
for appealing denied benefits.
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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.
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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 time frames 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.
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