Most adults under the age of 65 do not depend on Medicare for their health care, but are instead covered under an employer sponsored plan. If you are still working over the age of 65 an employer sponsored plan would still be your primary source of health benefits. It is to your advantage and your responsibility to understand how these benefits work and your rights under these benefits. These tips will help you to make your health insurance work for your benefit.
1. Your options are important.
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.
2. Reviewing 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 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 to help you compare your health care choices.
4. Have a copy of the health plan's summary plan description (SPD)
Your health plan administrator should provide a copy. It outlines your 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, 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.
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.
7. HIPAA can also help if you are changing jobs, particularly if you have a medical
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.
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. This information helps you in determining eligibility for Medicare and Medigap insurance coverage.
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 PWBA for customer service assistance if you are unable to obtain a response to your complaint.
10. Steps to improve of the health care and the health bene
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.
