If a worksite closes, how does an employee locate the plan administrator, or file a claim for benefits or obtain other documents such as certificates of prior coverage or replacement identification documents?
Category: Workplace Benefits Questions
Sub-Category: Health Benefits/Health Plans/Health Insurance
Answer:
Employers affected by an influenza pandemic may set up temporary work quarters, or will have made other provisions for their employees to contact them. The employer's representative should be able to give employees the name of the person to contact to obtain claim forms or other documents. The name of the plan administrator and the claims procedure may also be found in the health plan’s Summary Plan Description (SPD) that each employee should be provided upon enrolling in the plan. SPDs describe the plan rules in plain English. The SPD should also contain information on how to identify and locate the plan administrator, as well as steps to follow in applying for a benefit.
If they are having difficulty locating a contact person for the employer, employees may contact one of the Employee Benefits Security Administration’s (EBSA) benefits advisors at 1-866-444-EBSA (3272) or contact EBSA by email at askebsa.dol.gov.
Under the Health Insurance Portability and Accountability Act (HIPAA), a plan terminating coverage should provide participants and beneficiaries with a HIPAA certificate of creditable coverage that they can use to reduce or eliminate a preexisting condition exclusion in a later group health plan or to obtain an individual insurance policy. If an employee does not receive a certificate of creditable coverage from their plan by the time one is needed, employees may be required to demonstrate to a new plan or insurer that they have creditable coverage by attesting to the period of creditable coverage, producing some supporting evidence (such as a pay stub that reflects a deduction for health insurance, an explanation of benefits form, or verification by a doctor of prior health insurance coverage), and cooperating with an attempt to verify prior health coverage. If the prior health coverage was fully insured by an insurance carrier, the employee may request coverage verification from the insurer.
Note: As an overall matter, employers should be guided in their relationship with their employees not only by federal employment law, but by their own employee handbooks, manuals, and contracts (including bargaining agreements), and by any applicable state or local laws. Not all of the employment laws referenced apply to all employers or all employees, particularly state and local government agencies. For information on whether a particular employer or employee is covered by a law, please use the links provided for more detailed information. This information is not intended for federal agencies or federal employees -- they should contact the U.S. Office of Personnel Management (OPM) for guidance.
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Last Updated: 01/25/2008
