If you are confused in choosing your health plan or if it doesn’t providing the claims, then you are at right place to be guided for. You have rights to get information about how your health plan works and how to make claims for benefits. There are laws which help you to switch the plan in case of life changing events also. EBSA oversees health care laws covering special medical conditions. Here are some guidelines which can help you:

Choose your health plan carefully: Among different types of health benefit plans, select the one which fits you.  Check out each plan carefully and choose the best one for you. Gather information regarding the plans from your employer’s human resource (HR) office, the health plan administrator, or your union to help you match your needs and preferences with the available plans. A wrong plan can lead to lose instead of benefits.

Look for Quality: Your goal should target quality. The quality of health care services may vary. Every plan or doctor or hospitals provided do not give same quality service. Compare them and measure the quality before choosing. To measure and compare your health care choice, consult the U.S. Department of Health and Human Services publication at www.ahrq.gov/consumer/qntool.htm. It will readily provide the required information on this matter.

Take a review of the Benefits: Health benefits provided by the plans should be of high quality. Ask some questions while selecting like do the plans offered cover preventive care, well-baby care, vision or dental care? Are there deductibles? Matching your needs and those of your family members will result in the best possible benefits.

Ask for Plan’s Summary Plan Description (SPD): The health plan administrator usually provides a copy of plan summary which highlights the benefits provided and your legal rights under the Employee Retirement Income Security Act (ERISA). Ask the administrator for this summary report and go through the information about the coverage of dependents, what services will require co-pay, and the circumstances under which your employer can change or terminate a health benefits plan. It will give you a clear picture of your rights and benefits you will get in future. This can be used as guide to get any required information about the plan in future.

Case of life changing event: There may be provisions in case of life changing events like marriage, divorce, childbirth or adoption, or the death of a spouse. The SPD should cover about the change of plans in these critical conditions. 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). In normal cases also, there should be provision for switching the plan.

Also ask a copy of An Employee’s Guide to Health Benefits under COBRA.  Under the Consolidated Omnibus Budget Reconciliation Act, 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.

Retirement case: What are the health benefits which will be provided after retirement? Go through your SPD for the answer and consult with your employer’s human resources office, your union and the plan administrator. There should be no conflictions among the information and make sure there will be no change before you retire.

Right of making an Appeal in case Health plan Claim is denied: You should give a right to appeal or file a complaint in case claims by Health Benefit Plan are denied. Understand how the plan handles grievances and where to make appeals of the plan’s decisions. In future if such problem occurs, make sure there is some provision for that and check where to appeal and who will handle this.

Take Steps to Improve the Quality of the plan: Quality Reports and Accreditation Report scan be used to improve the Health Care plan whenever you can. Quality reports answers 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. While accreditation reports provide information on how accredited organizations meet national standards, and often include clinical performance measures.

In case your spouse’s employer also offers a health benefits package, coordinate both plans for maximum coverage.

For more information on the laws that protect your benefits, see EBSA’s Web site at www.dol.gov/ebsa.