1

Know what you have There is no such thing as a "standard" health plan. If you're lucky, your employer or insurer will provide you with a handy list of features. If not, you'll have to study your Summary Plan Description, a booklet you probably got when you first signed up for it. Most critical: good hospitalization coverage because hospital bills are by far the most expensive health care most people will ever use. We've created a standardized form to help you clarify your plan's provisions.

2

Sweat the details Remember, insurance isn't for when you're healthy--it's for when you're sick. Does the mental-health coverage include ample counseling visits, inpatient days, and substance-abuse treatment? How many days of physical therapy, in case you have a stroke? Good "durable medical equipment" coverage can make all the difference for someone who needs a breathing machine or a wheelchair.

3

Do the math Do a "worst case" calculation of your maximum annual costs. Here's how: Add up the total annual cost of your premium, plus your plan's annual out-of-pocket cap. If it's too high, you might want to trade higher premiums for a lower out-of-pocket limit. If you have enough money saved up to cope with an occasional bad year, your trade-off might go the other way.

4

Follow the rules Every major carrier offers many plans, each with distinct rules and requirements. Study your Summary Plan Description to make sure you know exactly what yours are because if you don't follow them, it could cost you. For example, you might go to the hospital for an operation that is covered by your insurance but you don't realize that one of the attending physicians is not part of your health plan. Then you could be on the hook for paying more than you expected. If you aren't sure whether a particular doctor participates in your plan's network, check not only with the insurance company but also with the doctor's billing staff.

5

Don't get locked out The 1996 federal Health Insurance Portability and Accountability Act protects people from losing coverage for pre-existing conditions when they switch jobs. Under HIPAA, insurers can't deny you complete coverage as long as you switch from one plan to the next within 63 days (more in some states) and your earlier coverage lasted for at least a year. Do what you can to avoid that 63-day gap, for instance, by joining your spouse's plan or continuing with your old job's health plan under federal COBRA rules.

6

Understand COBRA The 1986 federal Consolidated Omnibus Budget Reconciliation Act allows you to continue your group coverage after you leave your job (unless your group had fewer than 20 people in it). But you generally have to pay the entire premium, including the portion that your employer used to pay. If you have a serious condition, COBRA might be the only coverage you can get. You can usually stay on COBRA for 18 months. It's also helpful for young adults who "age out" of their parent's plan; they can keep COBRA for up to three years.

7

Fight back You are not completely at the mercy of your health plan's decisions on coverage and payment. You have certain rights under state or federal law to appeal health-plan decisions you think are wrong. For complete information, including a guide to state laws and procedures, consult "A Consumer Guide to Handling Disputes with Your Employer or Private Health Plan."