Those employers that provide health plan benefits to their workers should be well-versed in the policies and procedures that surround the various types of insurance coverage. The more knowledge you have as an employer, the easier it will be for your employees to set up, access, and reap the benefits of their health insurance that is provided through their place of work. It is important to be aware of the constantly changing regulations that deal with employer-provided health coverage. When you are properly informed as to what information employees are entitled to, what benefits they can receive, and what their legal privileges are in regards to their medical plan, you will be able to answer questions with confidence and insight.
ERISA and Health Plan Rights
Several decades ago, the Employee Retirement Income Security Act (ERISA) was passed, and today it continues to support employees and their employers by monitoring and governing participants’ access to their health plan information. ERISA regulates laws such as who can access an individual’s health benefits, when people are eligible for employee retirement benefits and under what circumstances those might be forfeited, and what information a plan is required to provide a participant with on a regular basis.
Summary Plan Descriptions
Within the broad ruling of ERISA is a specific mandate that states that employees and their family members are entitled to informative and thorough Summary Plan Descriptions that describe in detail the perks of their particular health care plan, how benefits occur within the plan, and the rights of the participants in the plan. All of the relevant figures of the health coverage plan must be present within the Summary Plan Description, including its monthly premium, deductible, coinsurance, and copayment and any restrictions or caps that limit these numbers. The guidelines must include information on how to access the benefits of the plan and what to do to appeal or file a complaint if any benefits are denied.
The coverage for health services, medical procedures, and health products must be included within the description, and it must reference the extent to which preventative medical care is covered. The summary is required to list information about what health providers are in-network and what health providers are out-of-network, details on the in-network coverage, and any consequences for seeking out-of-network care. Instructions must be given on how to go about choosing a primary care provider as well as a specialty care provider. Emergency medical care procedures and restrictions must be addressed within the document. Any circumstances in which a participant in the plan must require previous authorization or assessment before receiving other medical care is also a required aspect of the Summary Plan Description.
All of the information in the Summary Plan Description will provide workers and any plan beneficiaries with a comprehensive foundation regarding their plan. In addition, there is a good deal of further regulations that deal with a worker’s right to know of any changes in the plan. Employees must be notified of any decreases in benefits within 60 days of the change by way of a revised edition of the Summary Plan Description, which is also updated regularly.
Between the Summary Plan Description and the claims department of the health insurance company itself, a worker should have access to more than adequate information about their coverage at all times. Employees who have any further questions about their specific situations or the details of their medical benefits should consult the most recent version of their Summary Plan Description or contact the coverage department of their insurance provider. As an employer, being empowered with this information that you can share with your employees is critical to the success of a well-run and organized health insurance program.
The content on our website is only meant to provide general information and is not legal advice. We make our best efforts to make sure the information is accurate, but we cannot guarantee it. Do not rely on the content as legal advice. For assistance with legal problems or for a legal inquiry please contact you attorney.