**Skip to page content
United States Department of Labor
Subscribe to E-mail UpdatesAll DOL EBSA   Advanced SearchA to Z | 				Site Map | 				FAQs | 				Forms | 				About DOL |  				Contact Us |                 Espa�olEmployee Benefits Security Administration**DOL** > **EBSA** > **Newsroom** > **Fact Sheet**
Fact Sheet: Workers’ Right To Health Plan Information

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 137 million      Americans.

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.

Among other information, the SPD of health plans must describe:
-  Cost-sharing provisions, including premiums,          deductibles, coinsurance and copayment amounts for which the          participant or beneficiary will be responsible
-  Annual or lifetime caps or other limits on benefits          under the plan
-  The extent to which preventive services are covered          under the plan
-  Whether, and under what circumstances, existing and          new drugs are covered under the plan
-  Whether, and under what circumstances, coverage is          provided for medical tests, devices and procedures
-  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
-  Conditions or limits on the selection of primary care          providers or providers of specialty medical care
-  Conditions or limits applicable to obtaining          emergency medical care
-  Provisions requiring preauthorizations or utilization          review as a condition to obtaining a benefit or service under the plan

The SPD must also explain how plan benefits may be obtained and the      process for appealing denied benefits.

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.

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 timeframes 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.      

This fact sheet has been developed by the U.S.      Department of Labor, Employee Benefits Security Administration,      Washington, DC 20210. It will be made available in alternate formats upon      request: Voice phone: 202.693.8664; TTY: 1.202.501.3911. In addition, the      information in this fact sheet constitutes a small entity compliance guide      for purposes of the Small Business Regulatory Enforcement Fairness Act of      1996.    
Freedom of Information Act | 				Privacy & Security Statement | 				Disclaimers | 				Customer Survey | 				Important Web Site Notices |                 Plug-ins Used by DOL				U.S. Department of Labor | Frances Perkins Building, 200 Constitution Ave., NW, Washington, DC 20210www.dol.gov | Telephone: 1-866-444-EBSA (1-866-444-3272) | TTY: 1-877-889-5627 | Contact Us**