Workers' Right to Health Plan Information

The Employee Retirement Income Security Act (ERISA) governs approximately 2.5 million private-sector health benefit plans in the U.S. These plans provide a wide range of medical, surgical, hospital, and other health care benefits to over 130 million Americans.

Under ERISA, workers and their families must receive a copy of the Summary Plan Description (SPD) from their health plan’s provider. The SPD offers information about the plan, its benefits, the rights of participants and beneficiaries, and how the plan works.

This article explains employees’ rights to information on their health plans, including their right to updated SPDs and notice of any changes to the plan.

If you’re having issues with your health insurance plan, start by contacting your benefits coordinator. They’ll typically be part of your employer’s human resources department.

However, if your employer is not meeting their obligations or refuses to provide information, consider contacting an employment law attorney for help. They can evaluate the facts of your case and help you decide what to do next.

How Does ERISA Protect American Workers?

ERISA is a federal law that requires companies that manage and control private sector employee health plans to provide plan participants with specific information regarding their health insurance. If a plan fails to comply with ERISA, plan participants and their family members can sue for benefits and breach of fiduciary duty.

Specifically, ERISA covers the following:

• What information providers must give to members regularly
• Who can access workers’ health benefits
• When workers become eligible for employment retirement benefits
• When a participant forfeits their health insurance coverage and other benefits

The Employee Benefits Security Administration, part of the U.S. Department of Labor, oversees and enforces ERISA.

Who Does ERISA Protect?

ERISA protects people who work for private employers in the United States. Most people who work for large employers can purchase (or participate) in group health insurance plans. This gives workers access to affordable healthcare coverage.

However, ERISA does not cover people who:

• Are self-employed
• Purchase health insurance on their own
• Work for state or federal government agencies

Individuals who work for small businesses also may not have these protections. Small employers typically cannot afford to offer health insurance to their staff. If this is the case with your company, ERISA will not provide protection.

Does ERISA Protect Former Employees?

Under federal law, former employees qualify as plan participants for purposes of ERISA. They are entitled to the same information as current employees.

There are several situations where this extension becomes important, including when a former employee:

• Extends their plan coverage through COBRA
• Has an outstanding claim at the time of their termination
• Has an issue with unemployment insurance, unemployment benefits, or workers’ compensation benefits

Just as ERISA protects former employees, it also protects new employees. If someone starts with a new company, they will likely elect to participate in its health plan. If this is the case, they deserve the same rights and protections as existing employees.

Are Part-Time Employees Covered Under ERISA?

ERISA protects both part-time and full-time employees. However, eligible employees must work at least 1,000 hours in a year to enjoy ERISA protection.

It’s important to talk to your employer or plan administrator to learn if there are other eligibility requirements. Every plan is different, and it’s vital that you know where you stand. This is true not only for access to health insurance but also for things such as sick leave and protection under the Family and Medical Leave Act (FMLA).

Information Insurance Carriers Must Provide to Employees

ERISA requires that insurance companies provide specific information about how the plan works, what medical procedures it covers, and how participants can dispute denied claims.

Among other information, the SPD of health plans must answer the following questions:

• What are the premiums, deductibles, coinsurance, and copayment amounts?
• Are there annual or lifetime caps or restrictions on plan benefits?
• Which preventive services does the plan cover?
• What prescriptions does the plan cover?
• Is there coverage for specific medical tests, devices, and procedures?
• What are the requirements for using out-of-network providers?
• Which providers are in-network?
• Are there conditions or limits on the participant’s choice of primary medical care providers?
• What are the conditions or limits on emergency medical care?
• When does the participant need a pre-authorization or utilization review?

The SPD must also explain how participants can obtain benefits and appeal claim denials.

Providing Updates on the SPD

ERISA also requires that plan administrators update their SPDs periodically. Furthermore, ERISA requires plans to disclose any material reductions in coverage to members within 60 days of the change. The administrators can do this with an updated SPD or a summary of material modification (SMM).

Plan administrators must disclose material changes that do not reduce coverage within 210 days after the end of the calendar year in which the company adopts the change.

Participants’ Rights to Claim Decisions Under ERISA

One complaint many workers have about their health benefits is that the insurance company takes too long to approve (or deny) a claim.

For example, let’s say you go to the emergency room after developing food poisoning. You take an ambulance to the hospital. A couple of weeks later, you get a bill for $1,200 for ambulance transport. You thought your health insurance covered this, and submit a claim to the insurance carrier. Now, you have not heard anything for six months.

Under ERISA, plan administrators must outline the claims process so that participants understand what happens after they submit a claim for benefits. The plan’s SPD may include an “FAQ" section that answers participants’ questions about filing and appealing claims.

According to ERISA, insurance carriers must respond to participants’ claims in a timely manner. The SPD should describe the time frame for claim decisions, the claims process, and participants’ rights to notices and disclosures.

What Should You Do if Your Plan Doesn’t Provide the Information You Need?

It can be frustrating to have a health insurance company ignore a participant or refuse to discuss the participant’s claim. Sadly, this happens more often than one would think.

If you believe you have a valid claim under ERISA, there are specific steps you must take:

• Review your SPD and confirm your rights and benefits
• Gather all necessary documents and additional information related to your claim
• File a written claim with your employer or the plan administrator
• Wait for a response
• File a formal appeal if the plan still denies your claim or benefits

This process can be daunting. It’s a good idea to contact an experienced employment attorney for legal advice.

If you believe the plan administrators have discriminated against you, consider filing a claim with the Equal Employment Opportunity Commission (EEOC). The EEOC does not handle general ERISA claims, but they can take on cases involving discrimination. An attorney can help you determine whether it’s appropriate to involve the EEOC.

Where Can I Find Help?

If you’re dealing with issues related to your health insurance, you should talk to your company’s human resources department immediately.

If you feel your employer is treating you unfairly or not taking your concerns seriously, consult an employment law attorney in your area. FindLaw’s directory of local attorneys can help connect you with someone experienced in your type of case. You can narrow results by state, city, reviews, and other important factors to find the right legal advocate for you.