Health insurance benefits
Understanding some of the details in your health insurance policy can help you avoid unpleasant surprises.
Summary of benefits and coverage
Insurance companies and job-based health plans must provide you with a Summary of Benefits and Coverage. It lists the services covered and how the financial responsibilities will be split between you and the insurance company in an easy-to-understand summary format. This can generally be found through your employer's benefits website or through the website of the insurance company. You should be able to call your insurance provider and ask for the document for your plan as well.
In general, things to look for include:
- Does your policy have a deductible?
- Do you need a referral to see a specialist?
- Is prior authorization required?
- In case of emergency, how would you be charged for out-of-network providers or hospitals?
- What is the appeals process? In case a claim is denied, knowing your next steps could help reduce the stress of the potential bill.
- Check your maximum out-of-pocket limit and maximum out-of-network limit to find out your potential maximum liability.
Your insurance company may offer the services of a case manager to help facilitate care. While case managers working for insurance companies often proactively reach out to clients who have recently been hospitalized, you may be able to call and ask if your situation qualifies for one. Since they do work for the insurance company, their priority is keeping costs contained but they can also help you navigate the health care system and make sure you're able to get the care that is needed.
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Medical leave: Taking time off from work
State and federal laws protect eligible workers from discrimination and require employers to allow for medical leave if you're unable to do your job during illness or treatment.
The Family and Medical Leave Act
The Family and Medical Leave Act (FMLA) prevents discrimination against eligible employees who need to take unpaid time off work to care for a family member or due to illness. It provides up to 12 weeks of unpaid leave per year. The FMLA protects group health benefits if you need to take time off work for an illness. Your benefits must be maintained as though you had continued to work.1
The law also protects your job when you need to take time off. Your employer must give you the same or an equivalent position when you return.
To be eligible:
- Your employer must be covered by the law which includes all public employers, local, state, and federal; and private employers with 50 or more employees within 75 miles of the office the employee works in (or, for remote workers, the office the employee reports to) for at least 20 work weeks in the current or previous calendar years.
- You must have worked 1,250 hours for your employer during the 12-month period immediately before your leave.
- You must have worked for the employer for at least 12 months.
The Americans with Disabilities Act
People with diseases, like cancer for instance, or chronic conditions may be protected under the Americans with Disabilities Act (ADA). Under the ADA you can't be discriminated against because of your disability or illness—and you have the right to request reasonable accommodations from your employer as long as you can perform the essential functions of the job.
The ADA protects people who work for any employer with 15 or more employees. To be protected by the ADA you must have a record or evidence of substantial impairment that significantly limits or restricts a major life activity, such as hearing, seeing, speaking, walking, breathing, performing manual tasks, caring for oneself, learning, or working, according to the US Equal Employment Opportunity Commission.
Reasonable accommodations include:
- Modifying equipment or devices
- A part-time or a flexible schedule
Asking for a medical leave of absence
Once it's clear that you'll need to take time away from work, talk to your supervisor about the amount of time you may need. Your supervisor and your HR representative can explain your company’s policies around medical leave. Your employer may require proof from a health care professional explaining why you need the time off.
The FMLA requires that employers allow eligible employees to take up to 12 weeks of unpaid leave. Your employer's policies may be different. A small number of states, 4 in 2019, offer paid family and medical leave through taxpayer-funded temporary disability insurance funds: California, New Jersey, Rhode Island, and New York. The District of Columbia, Washington, and Massachusetts are in the process of starting insurance funds for paid family and medical leave. In the District of Columbia, benefits will begin in July 2020; in Washington, benefits will begin in January 2020; and in Massachusetts, they begin in January 2021.2
The state of Hawaii also requires employers to provide eligible workers with short-term disability insurance.3
Taking time off work generally means no paycheck unless you are off work due to disability. If you have short-term disability insurance through your employer, your HR representative or your supervisor may be able to help you request a leave of absence and file for benefits.
You can buy 2 types of disability insurance coverage, which pay a percentage of your income:
- Short-term disability coverage generally lasts about 6 months.
- Long-term disability coverage kicks in after the short-term policy would have run out—at the 6-month mark.
Some employers offer the opportunity to buy one or both types of disability insurance in a group policy as a benefit. Company-paid short and/or long-term disability is offered by some employers as part of their benefits package as well. You can also buy disability insurance on your own, outside of your employer.
But many people don't have disability insurance coverage. In 2018:
- 42% of people working for private employers had access to short-term disability insurance. Employers paid for coverage for 85% of the workers who had access to it.
- 34% of people working for private employers had access to long-term disability insurance. Employers paid for coverage for 94% of workers who had access to it.4
Disability insurance benefits are potentially available through Social Security, with an average monthly benefit of $1,234 as of December 2018.5 However, keep in mind, getting an initial decision on your disability claim from Social Security can take as long as 3 to 5 months.6