Making the Most of Your Group Health BenefitsAdd to My Luxx Living
Making the Most of Your Group Health Benefits
By William Scotti III
For millions of Americans, group health insurance offers affordable quality health care. To get the most from this valuable benefit, you need to understand what you have, how lifestyle changes can affect your coverage, and what to do if your coverage doesn’t meet your expectations.
Understand what you have
Get your plan’s summary plan description (SPD) from your plan administrator. It gives a detailed summary of your plan–how it works, the benefits it provides, and how those benefits may be obtained or lost.
Look for information on:
• Physician choice
• Accessibility of doctor’s offices
• Co-payment requirements
• Maximum out-of-pocket expenses
• Lifetime benefits
• Incentives for using the plan’s network of providers
• Waiting periods
• Prescription benefits
• Maternity benefits
• Dental and vision benefits
• Preventive care programs
• Member rights, including the right to appeal
• Quality reports and ratings from member-satisfaction surveys
Ask before you need it
Don’t wait for a serious illness or injury to learn what to expect from your group health plan. Now is the time to find out.
Take the time to learn the answers to the following questions:
• Do you need prior approval to visit a specialist?
• How does the plan define emergency care?
• How do you get care if you are outside the area?
• What hospitals are in the plan’s network?
• Is there a time limit on hospital stays?
• Get divorced
• Have a new child
• Have a child who is no longer dependent on you
• Suffer the loss of your spouse
The information provided by your employer should tell you how you can change benefits or switch plans if needed.
Planning for retirement
Find out what benefits are available during retirement. Ask your employer’s human resources office, union, and plan administrator.
Check your SPD. Make sure that all sources agree about the benefits you will receive and if they can be changed or lost. After you have this information, you can make other important choices, such as finding out if you are eligible for Medicare insurance coverage.
What can you do if a claim is denied?
Your plan administrator has a limited time after you file a claim to tell you if you will receive the benefits. If that is not enough time, you must be notified within a specified time why more time is needed and the date you can expect a decision.
Many states regulate claims processing and denial notification to members, so be sure to find out your insurance company’s time frames for processing claims, issuing denials, and resolving appeals.
If your claim is denied, you must be notified in writing and given specific reasons why it was denied. If you have no answer in the allotted time, the claim is considered a denial, and you can use the plan’s rules for appealing the denial.
If you disagree with any claims decision or preauthorization denial, you can request an appeal. It’s important to understand how your plan handles complaints. Check your health benefits package and your SPD to determine who is responsible for handling problems with benefit claims. Keep records and copies of all correspondence.
What if you are unhappy with your health care?
If you are in a managed care plan, you can change your primary care doctor if you are unhappy with the relationship. If the plan itself does not satisfy you, you may be able to switch plans. If you are dissatisfied with the managed care plan but prefer to remain in the plan because you want to remain with your physician, file a complaint.
You have the right to a fair and timely process for resolving your complaint. If you are still unhappy, speak to your employee benefits manager to help you match your needs with the available plans.
• Ask for a copy of the member handbook, sometimes called the evidence of insurance or evidence of coverage, to review coverage policies.
• Does your plan have a magazine or newsletter? Such a publication can give information on how the plan works and on rules that affect your care.
• Ask how you will be notified of changes in the plan’s medical providers or covered services and
• Talk to your plan administrator to learn more about your policy.
The more information you have, the easier it will be for you to make quality health-care decisions.
The accompanying pages have been developed by an independent third party. Commonwealth Financial Network is not responsible for their content and does not guarantee their accuracy or completeness, and they should not be relied upon as such.
These materials are general in nature and do not address your specific situation. For your specific investment needs, please discuss your individual circumstances with your representative.
Commonwealth does not provide tax or legal advice, and nothing in the accompanying pages should be construed as specific tax or legal advice.
Securities and Advisory Services offered through Commonwealth Financial Network, Member FINRA/SIPC, a Registered Investment Adviser. Fixed insurance products and services offered by Swift Financial Services, Inc.
William G. Scotti III CFP® is a financial consultant located at Axial Financial Group, 540 Main Street – Ste 16A, Hyannis, MA 02601.
He offers securities as a Registered Representative of Commonwealth Financial Network®, Member FINRA/SIPC. He can be reached at 508-771-4992 or at email@example.com.
Securities and advisory services offered through Commonwealth Financial Network, Member ww.FINRA.org/www.SIPC.org, a Registered Investment Adviser. Fixed Insurance products and services offered through Axial Financial Group. Commonwealth does not provide legal or tax advice. Please consult with a legal or tax professional regarding your individual situation.
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