TOP 10

WAYS TO MAKE YOUR

HEALTH BENEFITS

WORK FOR YOU

EMPLOYEE BENEFITS SECURITY ADMINISTRATION

UNITED STATES DEPARTMENT OF LABOR
Top 10 Ways to Make 

Your Health Benefits 

Work for You

 The Department of Labor’s

 Employee Benefits Security 

 Administration (EBSA) 

 administers several important

 health benefit laws covering 

employer-based health plans. They govern 

your basic rights to information about how 

your health plan works, how to qualify for 

benefits, and how to make claims for benefits.

In addition, there are specific laws protecting your 

right to health benefits when you lose coverage or 

change jobs. EBSA also oversees health care laws 

covering special medical conditions. For more 

information on the laws that protect your benefits, 

see EBSA’s Website at dol.gov/ebsa. Or call the 

agency toll-free at 1-866-444-3272 to reach a 

regional office near you. These 10 tips can help 

make your health benefits work better for you.

1. Explore Your Options for 

Health Coverage

You have options for health coverage. 

There are many different types of health benefit 

plans. Find out what your employer offers, then 

check out the plan (or plans). 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. Or consider a health plan through the Health 

Insurance Marketplace. Visit HealthCare.gov 

to see the health plan options available in your area. 

Get information about all of your options and review it. The 

more information you have, the better your health care decisions 

will be.
2. Review the Benefits Available

Do the plans offered cover the benefits 

that are important to you, such as mental 

health services, well-baby care, vision or dental care? 

Are there deductibles? What are the out-of-pocket 

expenses you may face? Determine your needs and 

priorities. Compare all of your options before you 

decide which coverage to elect. 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. Read Your Plan’s Summary 

Plan Description (SPD) for the 

Wealth of Information It Provides

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 also 

should contain information about the coverage of 

dependents, what services will require a co-payment 

or coinsurance, and the circumstances under which 

your employer can change or terminate a health 

benefits plan. You also can find many of the answers 

to your questions in the Summary of Benefits 

and Coverage (SBC), a short, easy-to-understand 

summary of what a plan covers and what it costs. You 

should receive a copy with your enrollment materials.

Save the SPD, the SBC, and all other health plan brochures 

and documents, along with memos or correspondence from your 

employer relating to health benefits.

4. Use Your Health Coverage

Once your health coverage has 

started, use it to help cover medical costs for 

services like going to the doctor, filling prescriptions 
or getting emergency care. Using your benefits will 

help you and your family stay healthy and reduce 

your health care costs. The Patient Protection and 

Affordable Care Act (ACA) provides many valuable 

protections for people enrolled in employmentbased health plans including prohibiting preexisting 

condition exclusions and annual and lifetime limits 

on essential health benefits. What’s more, many plans 

cover certain preventive services for free, including 

routine vaccinations, regular well-baby and wellchild visits, blood pressure, diabetes and cholesterol 

tests, and many cancer screenings. You also can keep 

your children on your health plan until age 26. Take 

advantage of your benefits, especially free preventive care if your 

plan covers it. If you were required to pay cost-sharing for a 

preventive service, check your Explanation of Benefits and ensure 

that the provider billed the service properly.

5. Understand Your Plan’s 

Mental Health and Substance 

Use Coverage 

Many health plans provide coverage

for mental health and substance use disorder 

benefits. If a plan does offer these benefits, the 

financial requirements (such as co-payments and 

deductibles) and the quantitative treatment limits 

(such as visit limits) for the mental health and 

substance use disorder benefits cannot be more 

restrictive than the financial requirements or 

treatment limits applied to medical/surgical benefits. 

Plans also cannot impose lifetime and annual 

limits on the dollar amount of mental health and 

substance use disorder services, including behavioral 

health treatment. Some plans cover preventive services like 

screenings for depression and child behavioral assessments 

for free. Check your SPD and SBC to find out what your 

plan covers. 

6. Look for Wellness Programs

More employers are establishing 

wellness programs that encourage 

employees to work out, stop smoking, and generally 

adopt healthier lifestyles. The Health Insurance 
Portability and Accountability Act (HIPAA) and the 

ACA encourage group health plans to adopt wellness 

programs but also include protections for employees 

and dependents from impermissible discrimination 

based on a health factor. These programs often 

provide rewards such as cost savings as well as 

promoting good health. Check your SPD or SBC to see 

whether your plan offers a wellness program(s). If your plan 

does, find out what reward is offered and what you need to do to 

receive it.

7. Know How to File an Appeal 

if Your Health Benefits Claim is 

Denied

Understand your plan’s procedures

for filing a claim for benefits and where to make 

appeals of the plan’s decisions. Pay attention to time 

limits – make sure you timely file claims and appeals 

and that the plan makes decisions on time. 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 assistance if you are unable to obtain a response to 

your complaint. 

8. Assess Your Benefits 

Coverage as Your Family 

Status Changes

Marriage, divorce, childbirth or 

adoption, the death of a spouse, 

and aging out of a parent’s health plan are life events 

that may signal a need to change your health benefits.

You, your spouse, and your dependent children may 

be eligible for special enrollment into other employer 

health coverage or through the Health Insurance 

Marketplace. Even without life-changing events, 

the information provided by your employer should 

tell you how you can change benefits or switch plans.

If you’re considering special enrollment, act quickly. You have 

30 days after the life event to request special enrollment in 

other employer 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 Benefits

If you change employers or lose your 

job, you may need to find other health coverage. If 

you have a new job, consider enrolling in your new 

employer’s plan. Whether starting or losing a job, 

you may be eligible to special enroll in a spouse’s 

employer-sponsored plan or through the Health 

Insurance Marketplace. Under the Consolidated 

Omnibus Budget Reconciliation Act - better known 

as COBRA - you, your covered spouse, and your 

dependent children may be eligible to continue 

coverage under your former employer-sponsored 

plan. This coverage is temporary (generally 18 to 36 

months) and you may have to pay the entire premium 

plus a 2 percent administrative charge. Get information on your coverage options and compare. Be aware 

of the deadlines for deciding on coverage and find out when 

your new coverage will be effective. 

10. 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, or 

the plan administrator. Check your SPD and other 

plan documents. 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. If you want to retire 

before you are eligible for Medicare and your 

employer does not provide health benefits in retirement, consider what you will do for health coverage. 

Your options may include enrolling in a spouse’s 

employer plan or in a Marketplace plan or temporarily 

continuing your employer coverage by electing 

COBRA. Planning for retirement includes planning for your 

health coverage in retirement. To find out more, read Taking the 

Mystery Out of Retirement Planning (see back panel).
These Laws Can Help

• The Employee Retirement Income 

Security Act -- Offers protection for individuals 

enrolled in retirement, health, and other benefit plans 

sponsored by private-sector employers, and provides 

rights to information and a claims and appeals process 

for participants to get benefits from their plans. 

• The Patient Protection and 

Affordable Care Act – Creates the Health 

Insurance Marketplace and provides protections 

for employment-based health coverage, including 

extending dependent coverage of children to age 

26; prohibiting preexisting condition exclusions and 

prohibiting lifetime and annual limits on essential 

health benefits.

• The Consolidated Omnibus Budget 

Reconciliation Act -- Contains provisions 

giving certain former employees, retirees, spouses, and 

dependent children the right to purchase temporary 

continuation of group health plan coverage at group 

rates in specific instances. 

• The Health Insurance Portability 

and Accountability Act – Allows employees, 

their spouses and their dependents to enroll in 

employer-provided health coverage regardless of open 

enrollment periods if they lose coverage or in the 

event of marriage, birth, adoption or placement for 

adoption. Also prohibits discrimination in health care 

coverage. 

• The Women’s Health and Cancer 

Rights Act -- Offers protections for breast cancer 

patients who elect breast reconstruction in connection 

with a mastectomy. 

• The Newborns’ and Mothers’ Health 

Protection Act -- Provides rules on minimum 

coverage for hospital lengths of stay following 

childbirth. 

• The Genetic Information 

Nondiscrimination Act -- Prohibits 

discrimination in group health plan premiums based 

on genetic information. Also, generally prohibits group 

health plans from requesting genetic information 

or requiring genetic tests. 
• The Mental Health Parity and 

Addiction Equity Act and the 

Mental Health Parity Act – Requires 

parity in financial requirements and treatment 

limitations for mental health and substance use 

benefits with those for medical and surgical benefits.

• The Children’s Health Insurance 

Program Reauthorization Act -- 

Allows special enrollment in a group health plan 

if an employee or dependents lose coverage under 

CHIP or Medicaid or are eligible for premium 

assistance under those programs. 

For More Information:

Visit the Employee Benefits Security Administration’s 

Website at dol.gov/ebsa to view the following 

publications. To order copies or to request assistance 

from a benefits advisor, contact EBSA electronically 

at askebsa.dol.gov or call toll free 1-866-444-3272.

• An Employee’s Guide to Health Benefits Under

 COBRA 

• Retirement and Health Care Coverage...

 Questions and Answers for Dislocated Workers

• Can the Retiree Health Benefits Provided 

 by Your Employer Be Cut?

• Your Health Plan and You – Know Your Health

 Coverage Protections

• Life Changes Require Health Choices...Know Your 

 Benefit Options

• Work Changes Require Health Choices...Protect 

 Your Rights

• Your Genetic Information and Your Health Plan – 

 Know the Protections Against Discrimination

• Taking the Mystery Out of Retirement Planning

You also may visit the U.S. Department of Health and 

Human Services Website at HealthCare.gov or call 

1-800-318-2596. This is where you can find out more 

about Marketplace plans, what they cover, and how to 

apply. You can also get information by contacting your 

state insurance commissioner’s office.

EMPLOYEE BENEFITS SECURITY ADMINISTRATION

UNITED STATES DEPARTMENT OF LABOR

December 2014