Ongoing benefits counseling

A: Yes. 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.

A: To qualify for the special enrollment period, you must notify the plan and request special enrollment for everyone enrolling within 30 days of your marriage. Your plan may require that the notice be in writing and that is usually the safest course of action anyway. If your spouse has health coverage available, compare the health benefits, cost and options under both plans, and decide which one works best for you.

A: When you're thinking about retiring, be sure you understand the documents governing your health care plan. Review your SPD, and any documents you have received that would modify it. Also, request copies of any formal written documents that outline how your plan operates, and any other information on your employer's policies on retiree health care benefits. Realize that although some employers continue to provide health care benefits to their retired employees, private sector employers are not required to provide retiree health benefits. And remember, federal law doesn't prevent employers from cutting or reducing health benefits under plans available to participants and their families, unless there has been a specific promise to continue them that can be legally enforced. So before you retire, think about saving money to use for any coverage gaps that may occur before you are eligible for Medicare.

A: Get all the details on your spouse's plan, and be sure you understand how it works. You'll want to know the amounts of any deductibles or copays you will be required to pay, and what you will pay for premiums.
Under the Health Insurance Portability and Accountability Act ("HIPAA"), you may be entitled to add yourself, a new spouse and children to your employer's plan or to your spouse's employer's plan under a special enrollment period.

A: HIPAA places limits on the amount of time a pre-existing condition exclusion period may apply. In addition, health care plans cannot consider pregnancy a pre-existing condition, even if the woman did not have previous coverage.

Birth and adoption (including placement for adoption) may trigger a special enrollment period during which you, your spouse and new dependents can enroll in your employer's plan. Additionally, newborns and adopted.

A: Most health care plans will provide coverage to dependent children until they reach the age of 19, or the age of 25 if they are full-time students. Once your child loses "dependent child" status under your health care plan's rules, the child may be eligible to purchase temporary extended health care coverage for up to 36 months under the Consolidated Omnibus Budget Reconciliation Act("COBRA"). Generally, COBRA covers group health plans maintained by employers with 20 or more employees.

Once your covered child is no longer a dependent, notify your employer in writing within 60 days. In turn, your plan should notify your child of his or her right to extend health care benefits under COBRA. Your child will have 60 days from the date the notice was sent to elect COBRA coverage. The cost will be higher, since the employer will no longer pay a portion, but it is usually less than the cost of individual coverage.

NOTE: Ages may differ depending on the state in which the insurance is in effect.

A: If an employer declares bankruptcy, it will generally take one of two forms: reorganization under Chapter 11 of the Bankruptcy Code, or liquidation under Chapter 7. A Chapter 11 (reorganization) usually means that the company continues in business under the Court's protection while attempting to reorganize its financial affairs. A Chapter 11 bankruptcy may or may not affect your pension or health plan. In some cases, plans continue to exist throughout the reorganization process. In a Chapter 7 bankruptcy, the company liquidates its assets to pay its creditors and ceases to exist. Therefore, it is highly likely your pension and health plans will be terminated.

A: The following documents contain valuable information about your health and pension plans and should be helpful to you. You should be able to obtain most of them from your plan administrator, employer or union representative:

• Summary Plan Description - A description of your pension and health plan
• Summary Annual Report (not available for some plans)- An annual summary of the plan's finances that may contain names and addresses you may need to know
• Earnings and leave statements - These are your pay stubs and may help you establish your employment dates, compensation, and contributions to a plan
• Certificate of creditable coverage (available upon request even if you still have health coverage and provided automatically when your health coverage ceases) - A certificate of creditable coverage is a statement of your past health care coverage with your employer
• Individual benefit statements showing how much money is in your pension account (for individual account plans) or the value of your pension benefit (for defined benefit plans)

A: Generally HIPAA limits pre-existing condition exclusions to a maximum of 12 months (18 months for late enrollees). HIPAA also requires this maximum period to be reduced by the length of time you had prior "creditable coverage." You should receive a certificate documenting your prior creditable coverage from your old plan when coverage ends. HIPAA may also give you a right to purchase individual coverage if you have no group coverage available, and have exhausted COBRA or other continuation coverage.

A: When an employee covered under an employer-sponsored health plan dies, legally separates or divorces, the covered spouse and dependent children may be eligible to purchase temporary extended health coverage for up to 36 months. The cost will be higher, since the employer will no longer pay a portion, but it's usually less than the cost of coverage you might get on your own.

If the spouse losing coverage under the plan has a health plan available through his or her employer, the spouse and any dependents may be eligible to obtain coverage through special enrollment.

If the covered employee dies or in the event of a legal separation or divorce, the plan should notify the covered spouse and dependent children of their right to purchase extended health care coverage under COBRA. Most plans require eligible individuals to make their COBRA election of coverage within 60 days of the plan's notice.

Should the employee who is covered by the health care plan die, the employer must notify the plan within 30 days. If there is a divorce or legal separation, the covered employee, spouse or dependent children must notify the plan in writing within 60 days. In case of death of the covered employee, divorce or legal separation, the plan should notify the eligible spouse and dependent children who would lose coverage under the plan of their right to purchase temporary extended health care coverage. Most plans require eligible individuals to make their COBRA election within 60 days of the plan's notice.

If the spouse losing coverage under the plan has a health plan available through his or her employer, the spouse and dependent children may be eligible for a special enrollment under that plan. To qualify, the spouse must notify that plan and request special enrollment within 30 days of the loss of coverage.

A: If you have unpaid health claims and your plan sponsor has declared bankruptcy, you may want to consider filing a proof of claim with the bankruptcy court.

A: If your employer discontinues all its health plans, COBRA continuation coverage will not be available. You will have to seek other coverage. Other coverage may be available by converting your employer's group health coverage to an individual policy. You may also have rights to special enrollment in a spouse's employer's plan, or by being an "eligible individual" who is guaranteed access to individual insurance. The opportunity to buy an individual insurance policy is the same whether the individual is laid off, fired or quits his or her job.

A: Your group health plan must notify you within 60 days of any reduction in benefits. If a reorganizing employer maintained several health plans and discontinues most of its plans, you may be eligible to continue coverage in its remaining plan. If you are covered under your employer's health plan and you lose your job, have your hours reduced, or get laid off and lose coverage as a result, you and your dependents may qualify for COBRA continuation coverage. COBRA provides a right to purchase extended health coverage under your employer's plan.

A: A group health plan is an employee welfare benefit plan established or maintained by an employer or by an employee organization (such as a union), or both, that provides medical care for participants or their dependents directly or through insurance, reimbursement or otherwise.

A: Most private sector health plans are covered by the Employee Retirement Income Security Act (ERISA). Among other things, ERISA provides protections for participants and beneficiaries in employee benefit plans (participant rights), including providing access to plan information. Also, those individuals who manage plans (and other fiduciaries) must meet certain standards of conduct specified in the law.

A: The plan must provide:

• 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 and
• 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.

A: When your employer files for bankruptcy, you should contact the administrator of each plan or your union representative (if you are represented by a union) to request an explanation of the status of your plan or benefits. The summary plan description will tell how to get in touch with the plan administrator. Questions that you might want to ask include:

• Will the plan continue or be terminated?
• Who will be acting as plan administrator of the plans during and after the bankruptcy, and who will be the trustee in charge of the pension plan?
• If the pension plan is to be terminated, how will accrued benefits be paid?
• Will COBRA continuation coverage be offered to terminated employees?
• If the health plan is to be terminated, how will outstanding health claims be paid, and when will certificates of creditable coverage (showing, among other things, the dates of enrollment in your employer's health plan) be issued?
  

A: 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 don't 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.

A: The Pension and Welfare Benefits Administration (PWBA) of the U.S. Department of Labor is responsible for administering and enforcing these provisions of ERISA. Click on the agency to find out more about the agency's program. As part of carrying out its responsibilities, the agency provides consumer information on health plans as well as compliance assistance for employers, plan service providers and others to help them comply with ERISA.