Are You Covered If....?

Health insurance coverages are extremely confusing and as a result, rarely understood.   What questions should you ask your provider before you join?  At what times should you review/change your coverage?  How does your provider handle claims?  Knowing the answers to these questions and others will help you immensely should you ever need to utilize your policy.

The following information was obtained from Forefield Inc., one of our Firm’s primary resources for financial planning.

HEALTH INSURANCE COVERAGE

Group health insurance offers affordable, quality health care for many of us.  To get the most from this valuable benefit, we need to understand the policy we have, how lifestyle changes can affect our coverage, and what to do if our coverage does not meet our expectations.

Get a copy of the plan's Summary Plan Description (SPD) from the plan administrator.  It provides 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 doctors’ offices
• Deductibles
• Co-payment requirements
• Maximum out-of-pocket expenses
• Lifetime benefits
• Incentives for using the plan's network of providers
• Exclusions 
• 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

Don't wait for a serious illness or injury to learn what to expect from the group health plan.  Now is the time to find out.  Take the time to learn the answers to the following questions:

• Is prior approval required to visit a specialist? 
• How does the plan define emergency care? 
• How can care be obtained if you are outside the area? 
• What hospitals are in the plan's network? 
• Is there a time limit on hospital stays? 
• Who decides when you will be discharged? 
• Will the plan pay for follow-up care, such as nursing home care or home health care? 
• If you have a serious medical problem, will the plan provide someone to oversee care and make sure your needs are met? 
• Are second opinions required for surgery? If so, who pays? 
• How do you get ambulance service? 
• Is there an advice hot line to help decide how to handle a problem that may not require a doctor's visit?

Always be proactive.   Don't be afraid to ask your doctor questions, and insist on clear answers.  If you're concerned that you won't be able to understand or follow a doctor's instructions, bring someone with you or take notes. 

Take responsibility for your own care by researching:

• Lifestyle choices and changes you can make to lower your risks or prevent illness (e.g., losing weight) 
• The risks and benefits of any tests or treatments 
• How you would go about obtaining care after hours

What happens when you lose coverage?  The Consolidated Omnibus Budget Reconciliation Act of 1986 (COBRA) allows you to purchase health coverage under your employer's plan if you lose your job, change jobs, get divorced, or upon the occurrence of other qualifying events.  Coverage that you obtain under COBRA can last from 18 to 36 months, depending on your situation.

COBRA applies to most employers with 20 or more workers and requires your plan to notify you of your rights.  Most plans require you to make an election for coverage under COBRA within 60 days of the plan notifying you.  Follow up with your plan administrator if you don't get a notice and make sure that you reply within the allowed time.

When you buy the insurance under COBRA, you must pay the full premium amount, plus administrative costs of up to 2 percent.  If you were accustomed to sharing health insurance premiums with your employer, you may be in for a shock.  However, if you or any family member have pre-existing conditions, you may not have any other choice, at least until you get into a new group plan.  You must remember to pay your premiums on time, or you will lose your coverage.

The medical coverage under COBRA must be identical to the coverage you had before.  However, employers may drop benefits such as dental care and vision care.

As your lifestyle changes, so do your insurance needs.   Review your group health insurance benefits and options when you:

• Get married
• 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.

You may also need to plan 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.

How should denied claims be handled?  After you file a claim your plan administrator has a limited amount of time to tell you if you will receive the benefits.  You must be notified within that specified time if more time is needed, why it is needed, and the date on which 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 you have no answer in the allotted time, the claim is considered a denial.  You will, however, still be notified in writing at some point and given specific reasons why it was denied.  Each plan has its own rules for appealing the denial, but all plans allow you to request an appeal if you disagree with a claim’s decision or preauthorization denial.

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 not happy with the health care provided under your plan?  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.

Always stay informed about your health care benefits and options.  

• Ask for a copy of the member handbook, sometimes called the evidence of insurance or evidence of coverage, to review coverage policies.  
• Check to see if your plan has a right-to-privacy policy.  Make sure that the plan requires your consent to release any medical information about you to outside agencies not involved with your direct health care or the administration of your health policy, especially your employer.  
• 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 prescriptions.  

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.

Reviewing your policies is a great way to start the new year!  Our Financial Planning Group is available to address all your financial planning needs and concerns.   Please call us or email us.