Individual and Group Health Insurance
Good health insurance coverage is very important for survivors. Without insurance coverage, you may be responsible for the costs of medical procedures, visits with your health care team and prescribed medications or equipment. Health insurance helps make the medical care you need affordable. Knowing about individual and group health insurance plans and coverage options may help you choose the health insurance plan that enables you to receive the best treatment and health care services for your specific needs.
Individual and Group Health Insurance: Detailed Information
This information is meant to be a general introduction to this topic. The purpose is to provide a starting point for you to become more informed about important matters that may be affecting your life as a survivor and to provide ideas about steps you can take to learn more. This information is not intended nor should it be interpreted as providing professional medical, legal and financial advice. Please read the Suggestions document for questions to ask and for more resources.You should consult a trained professional for more information.
Health insurance plans provide coverage to pay medical expenses when you are ill or injured. Most plans also pay for examinations, diagnostic tests and other preventative services to keep you well. Each health plan defines what is covered and the benefits that are available under their individual policy. Good health insurance is very important for cancer survivors. Without health insurance coverage, you will be responsible for the full costs of medical procedures, visits with your health care team and prescribed medications. In addition, without coverage you may have difficulty accessing needed care. Health insurance helps make the medical care you need affordable and obtainable.
Learning about health insurance plans and coverage options may seem overwhelming because there are many types of coverage available. However, it is important to understand your insurance coverage options. The health plan you choose can affect which doctors you can see, as well as the treatment and health care services you receive.
This document provides an overview of the most common types of health insurance plans. It also discusses ways to get the best and most affordable health insurance coverage for your situation and addresses the following areas:
- Defining common insurance terms
- Knowing how laws affect health insurance coverage
- Understanding health insurance
- Comparing group health plans to individual health insurance plans
- Defining types of group and individual health insurance plans
- Finding a health insurance plan to meet your needs
- Evaluating a health insurance plan
- Getting the best health insurance rates
- Dealing with the insurance process and claim denials
- Finding other health care coverage
Defining Common Insurance Terms
The following provides a brief definition for commonly used insurance terms:
Appeal: The process of requesting the insurer to reconsider a claim decision.
Benefit: The amount the insurance company pays to a claimant or beneficiary when the insured person suffers a loss or injury.
Claim: The form submitted to the insurance company by a health care provider or patient that requests payment for medical services or items.
Co-Payment (co-pay): A specified fee that the policyholder pays for health care services that is in addition to what the health insurance covers.
Deductible: The specified amount which the insured individual is required to pay each year towards certain medical expenses before the health insurance company will reimburse for covered health care expenses.
Exclusions: The things that are not covered by an insurance policy, such as certain types of illness or pre-existing conditions.
Exclusionary period: The period of time specified in a policy during which certain medical services may be delayed, not covered or limited in benefit.
Health care provider: A doctor, nurse, hospital, medical lab or others who deliver medical or health-related care.
Lapse: When an insurance company ends insurance coverage for non-payment of the policy premium.
Medical underwriting: A process during which the health insurance company looks at an applicant's health history and other factors to decide whether to offer insurance coverage. This process also defines coverage for specific conditions and sets the amount of the premium (periodic payment) for plan coverage.
Open enrollment: A period of time, usually scheduled annually, during which employees can select from the health plans their employer offers.
Policy: An insurance contract that defines insurance coverage and the specific terms of the health plan.
Pre-existing condition: The specified length of time during which medical care was received for a health problem prior to the effective date of insurance coverage. Medical care may include the use of prescription drugs and physician services.
Premium: The monthly or yearly amount you or your employer pays for health insurance coverage.
Qualifying event: Life events during which you or your family member may be able to change your insurance coverage outside of open enrollment. Examples include voluntary or involuntary job loss, reduction in the number of hours worked, transition between jobs, death, change in marital status, change in number of dependents (birth or adoption of a child) or loss of dependent status.
Knowing How Laws Affect Health Insurance Coverage
The following is a broad overview of how two federal and state laws affect various types of health insurance plans:
- Consolidated Omnibus Budget Reconciliation Act of 1986 (COBRA):
COBRA is a federal law that provides employees, and other qualified beneficiaries who are covered by a group health plan, the right to choose to continue their health benefits for a specified period of time.
COBRA generally applies to employers who have 20 or more employees. This coverage is generally offered under qualifying events, such as voluntary or involuntary job loss, reduction in the number of hours worked, transition between jobs, death, divorce, loss of dependent status, as well as other life events. Coverage is for limited periods (typically 18, 29 or 36 months) depending on the health plan and the qualifying event.
COBRA requires specific notification requirements of the employer, employee and plan administrator. For example, there is a specified time by which employees must be notified of their right to elect to continue health coverage under COBRA. In addition, an employee has a limited time (usually 60 days) to formally request ongoing coverage after receiving the notification of the right to elect continuation of health coverage under COBRA. If you decide to purchase COBRA coverage, you will have to pay the full premium for this type of coverage so it is likely to be costly.
Some states have also enacted laws that are similar to the federal law. Check to see if there is such a law in your state.
- Health Insurance Portability and Accountability Act (HIPAA) of 1996:
HIPAA is a federal law that provides protections for beneficiaries covered by group health insurance. It limits the time during which health insurance policies can refuse coverage of health conditions that started before the health insurance policy took effect (pre-existing conditions). HIPAA also provides protections for renewability and availability of health insurance.
States also have privacy laws that address many of the same privacy areas as HIPAA, such as patient consent and access to medical records. If a state law provides more protection to the patient, then it takes precedence over HIPAA. On the other hand, if the federal law offers more protection, then HIPAA rules are given precedence.
HIPAA requires health insurance plan coverage for a pre-existing medical condition without a waiting period when joining a new group insurance plan if:
- You had health insurance, with no gaps in coverage longer than 63 days or more, and
- You had health insurance for at least the previous 12-month period
This means that you can go from one group health plan to another without exclusion for a pre-existing medical condition so long as you maintain continuous coverage.
Late enrollment in a plan must be allowed outside of open enrollment if you have lost eligibility for the previous health coverage or if the benefits have been lost or decreased, including an increase in the premium. If you decline coverage when you are eligible and do not have coverage of any kind at the time, the insurer can require you wait until the open enrollment, and the length of the pre-exclusion can be lengthened to 18 months.
Always discuss the details of a health insurance plan's coverage before making a decision to enroll in the plan. If a pre-existing condition could affect your health insurance coverage, it is especially important to get plan specific information from your employer's human resources department or the benefits administrator of your health plan. You may be able to receive full or partial credit which can reduce or eliminate the pre-exclusion period.
Laws regarding premium rates and how insurers can issue group health policies to employers vary greatly from state to state. In addition, the rules about group health plan coverage for large employers (more than 50 employees) are different from those for small employers (50 employees or less). These differences may affect when and how cancer survivors and others with a pre-existing medical condition are covered.
Understanding Health Insurance
If you already have health insurance coverage, start by reviewing your existing health plan. Next, make a list of all your current and projected health care needs for services and treatments. Compare your present plan benefits to your anticipated medical needs to decide whether you have the right type of coverage.
Keep in mind that you must continue to pay all of your policy premiums in full and on time to keep your health plan coverage. An insurance company cannot deny payment for covered medical services when a policy is active and if you have followed all of the administrative rules of the insurance policy, such as getting pre-authorization for coverage when the plan requires it. However, if you do not make the required premium payment for your plan coverage on time, your plan will lapse and your health coverage will end.
If your health insurance policy is cancelled, finding good coverage with a new health insurance plan is likely to be very challenging for someone with a medical history, such as cancer. In addition, a new individual policy could include higher premiums, extended waiting periods for coverage, and waived or excluded insurance benefits due to your medical history.
If you have no health insurance at this time, a review of your medical needs will help you identify the type of insurance coverage to get. You will need to make certain the plan you select will cover your health care providers, including doctors, hospitals, diagnostic services and therapists. It is also important to find out if your prescribed medications will be covered at the level that you need.
Many people are able to obtain health insurance coverage as an employment benefit. However, if you are not working for someone else, or if your employer does not offer a health plan, you will need to find health coverage in other ways. For example, you may be able to get coverage through membership in another group or by purchasing an individual health insurance policy. Often, health coverage can be obtained through a spouse or dependent option offered through a family member's plan.
Comparing Group Health Plans to Individual Health Insurance Plans
The following table compares the two broad categories of health insurance coverage that may be available to purchase: group and individual health insurance plans.
Group health plans provide coverage for qualified group members and sometimes their dependents.
Insurers make group health insurance plans available to membership groups, such as employers, credit unions, labor unions and trade associations.
The premium that you have to pay for coverage through a group health plan is usually much less than through an individual health plan. An employer may pay a portion of the premium cost.
If you are self-employed and have no insurance benefits, check with your state insurance commission to find out whether you are entitled to "group of one" coverage. This type of coverage provides the protections of group coverage.
Individual health insurance plans provide coverage through single insurance plan policies and not as a part of a group plan.
Because you purchase the plan as an individual, the premium cost tends to be more expensive than the premium for a group policy.
If you are self-employed, not working or work for an employer that does not provide health insurance benefits, you may find that purchasing an individual health insurance policy is your only option.
Individual health insurance coverage may be very difficult to find if a cancer survivor is in the active treatment stage. In addition, an individual health policy may then exclude coverage for cancer-related medical expenses for a specified length of time after treatment is completed.
How to Purchase
Group health coverage may be available through an employer or another group. Your relationship or membership with that group may qualify you to participate in their health insurance benefit plan.
An employer may pay all of the plan costs. However, often an employer pays a portion of the health insurance cost and the employee is also required to pay a portion. There may also be an option for extra insurance coverage if you are willing to pay an additional amount.
An employer's group health plan typically offers an open enrollment period once a year. During this time you may have an opportunity to join or change your current plan options and add eligible dependents, such as a spouse or child.
Some changes in your life may enable you to change insurance coverage outside of the open enrollment period. Contact your plan administrator for specific information about qualifying events and the terms of coverage your plan allows.
Note: There is typically a specified time, such as 31 days, of the qualifying event during which you must notify your benefits administrator in order to be eligible to change your benefit coverage.
If you need to purchase an individual health policy, talk with an insurance professional to learn more about the many types of plans that are available to individuals.
Be aware that some programs call themselves health plans, but do not offer insurance coverage. Instead, they provide prearranged discounts with certain medical providers for the cost of health care services.
Find out if the insurance company selling the plan you are thinking about buying is accredited and licensed to operate in your state.
During the open enrollment period of the health insurance plan, carefully review the plan benefits as the coverage may change from year to year. This is the one time each year during which you may make changes to your group health insurance coverage without having to go through a pre-existing condition exclusion period.
A pre-existing exclusion may be applied if you have a medical problem which exists at the time you enroll in or purchase your health insurance. In that case, the insurance company is likely to deny all claims pertaining to this medical problem for a specified period of time.
Be sure to investigate insurance companies and the plans they offer before deciding to purchase a policy. Make certain the plan includes coverage that meets the needs of you and your family.
The Department of Insurance in your state can provide important information about insurance companies. Find out:
- If the insurer is currently licensed in your state
- Whether disciplinary actions have been filed against the insurer for business practices
- If beneficiaries have had concerns or negative experiences with the insurer in the past
Defining Types of Group Health Insurance Plans
- Fully-Insured: Employers may purchase this type of group health insurance for their employees through an insurance company. Premium payments are contributed by employees to cover the cost of the purchase price of the health plan.
- Self-Insured with a Third Party Administrator: This type of group health coverage is provided by employers who pay for their own claims, but contract with an insurance company to process claims and oversee the administration of benefits. Employee premium contributions are kept in a health care fund to be used specifically for beneficiary claims. Benefit coverage may either be determined by the employer or chosen from a list of existing products offered by the contracted insurer.
- Self-Insured: Employers who both process and pay for their own claims provide this type of coverage. Employee premium payments are kept in a health care fund and used specifically for beneficiary claims. Benefit coverage is determined by the employer.
The Department of Labor governs all self-insured plans while the state Department of Insurance administers fully-insured plans. The type of policy you have determines the regulatory body. It may be Centers for Medicare and Medicaid Services (CMS), the Department of Labor (DOL), or your state Department of Insurance (DOI). Your state DOI can tell you if additional protections apply to you if you are covered by a fully insured group health plan or an individual plan.
- Small-Employer Group Health Plans
Guaranteed issue refers to the federal requirement that insurers cannot deny coverage for small-employer group health plan members due to a pre-existing health condition. In addition, if the employer chooses to renew the health plan contracts every year, the insurance company must do so unless:
The insurance premium is not paid or
- The employer commits fraud or
- The employer does not comply with the terms of the health insurance contract
In most states, small employer group health insurance companies can review the medical histories of applicants for individual policies for pre-existing conditions. If an applicant is found to have a pre-existing medical condition diagnosed or treated within six months prior to joining the new plan, the insurer can decide not to cover certain conditions for a certain length of time.
Federal law sets the exclusionary or pre-existing condition waiting period for the time that your insurance plan does not cover certain pre-existing health conditions at 12 months. However, some states have reduced the allowable time. For more information about your state's coverage requirements for small group employer health plans, contact the National Association of Health Underwriters (NAHU).
- Large-Employer Group Health Plans
Large employer groups are not required to offer health insurance. In addition, a health insurance company could refuse to sell a health policy to an entire large-employer group because of the medical history of its plan members. However, if a large group employer has an active policy, an eligible employee cannot be denied health benefits based on their individual medical history. If an insurer issues a large group employer policy, then all of the eligible employees must be covered.
Defining Types of Individual Health Insurance Plans
In most states, if you are applying for individual or family health insurance through your state, your application will have to go through a medical underwriting process. Following this review of your health history and medical records, the insurer will determine if they are willing to provide you with health insurance coverage. Sometimes an insurer is willing to cover you, but at a higher rate if you have had a medical condition like cancer. Other times, the insurance company may exclude certain coverage (exclusionary provisions) or will not sell you a health insurance policy.
There are two general types of health insurance plans available within both group and individual health plans: indemnity plans and managed care plans. Most health insurance plans combine some elements of both types. The following table compares the basic elements of managed care and indemnity health plans:
Indemnity plans are also called fee-for-service plans. This type of plan allows policyholders to use any of the health services that are covered by the plan when they need health care.
Indemnity plans allow policyholders to choose physicians, (including specialists, such as oncologists and surgeons), hospitals and other health care providers for medical care. There is no specific network of approved medical providers.
If the health care service is covered under the provisions of your plan, the insurer pays a certain amount (usually a percentage) of the medical expense, as defined by the plan.
Managed care plans have arrangements with certain physicians, hospitals and health care providers to serve patients who are plan members at a contracted reduced rate.
Managed care plans usually offer a lower premium and require less paperwork. However, the choice of physicians, drugs and treatment are restricted.
The insurer covers treatment provided by physicians and other medical service providers from the company's network (approved providers). This leaves the patient responsible for a designated co-payment or cost share.
Some plans offer benefits for care that is received outside the approved network of medical providers, but you pay a higher co-payment, as well as the difference in cost for the medical service.
A managed care health plan may only pay for medications that are on the insurer's list of approved drugs.
Indemnity plans require a deductible, which is an amount of money (specified by your plan) that you have to pay each year before costs of medical services are paid by the plan.
Indemnity plans may also require you to pay a co-payment. That is a fixed fee specified by the plan, usually as a percentage (such as 20 percent), of the cost of medical services covered by the plan. Co-payments are in addition to the deductible that you must pay.
Many health plans include a stop-loss provision, which means the plan will pay 100% of allowable charges after you have paid a specified out-of-pocket amount, such as $1500.
In some cases you may also be required to pay the difference between what the insurer considers as reasonable costs, and will pay, and what the medical provider actually charges for services.
Indemnity plans pay their share of medical expenses after they are billed and have reviewed the insurance claim.
With managed care plans, such as a Health Maintenance Organization (HMO), you may be required to select a primary care physician (PCP), who is a member of the plan network, to take care of your general medical needs.
General medical needs may include treatment for common illnesses, preventive care and annual exams. Your PCP must make the determination to refer you to a specialist, such as an oncologist. Under an HMO, you cannot have coverage for services through a specialist without a referral from the PCP.
The premium cost for managed care health coverage is generally less than an indemnity plan. You also pay a co-payment (such as $10 or $25 per visit) each time you meet with your PCP or other medical provider who is a member of the plan network.
The most common health insurance options that use indemnity or managed care plans include:
- Health Maintenance Organization (HMO): An HMO contracts with certain health care providers to provide prepaid services to plan members. There is usually a set fee or co-payment for office visits and other medical services. This type of plan requires a PCP and referrals are required to receive care from specialists within the HMO network of providers. Some HMOs may allow you to see certain commonly used specialists, such as an obstetrician-gynecologist, without a referral from the PCP.
- Independent Practitioners Association (IPA): An IPA is group of independent physicians and other medical providers (may include hospitals and medical centers) who contract with health plans, such as HMOs and Medicare Advantage plans, to provide specific services at contracted rates. In most cases, health care coverage is only provided within that network, with the possible exception of emergency or urgent care services.
- Preferred Provider Organization (PPO): A PPO plan may recommend but not require that you work with a PCP. Instead, you can work with a large number of medical providers who participate as a member of the plan network. There is also an opportunity to receive health care services with providers who are not in the network, but you may be required to pay the difference between the amount billed and the amount allowed by your insurance company. This is likely to result in increased out-of-pocket expenses for you, such as a higher co-payment. PPO plans may have higher premiums and per-visit costs than HMO plans.
- Point-of-Service Plan (POS): A POS plan offers more flexibility and choice regarding medical providers and facilities. If you see providers in the HMO network, your costs are at the HMO rate. However, you have the option to seek services from a larger network of providers, as in a PPO. If you seek services from the PPO providers, you will have higher costs for having this greater flexibility.
- These plans reimburse at a set percentage rate regardless of who provides the medical care. You have a choice regarding providers and facilities, although you may be encouraged to work with a PCP who can make referrals for care within the plan network. If you go outside the plan network, you must make certain that the medical provider is willing to accept the payment that the POS plan has assigned or you may be billed for the balance for the health services provided. POS plans were created by HMOs to give members more treatment options, but the premium is typically higher.
- High-Deductible Plan: This type of health insurance plan includes Health Reimbursement Arrangements (HRA), also called Consumer-Driven Plans (CDP). High-deductible plan coverage (usually a PPO) begins after you have paid the high-deductible amount each year, ranging from $1,000 to $5,000 of covered medical charges. Although these plans have less expensive premiums, some policyholders may be tempted to seek medical services less often because every year they are required to pay the full amount of deductible costs for medical services before the insurer starts to pay for services.
- Health Savings Account (HSA): An HSA is a supplement to a high-deductible health insurance policy. These accounts do not replace health insurance polices. They are a pre-tax savings plan that builds funds like an individual retirement account (IRA) for payment of medical expenses. An HSA allows you to use tax-free funds to cover medical expenses not covered by your health insurance policy, such as fertility treatments, chiropractic services, eye care or acupuncture.
- Flexible Spending Arrangement (FSA) and Medical Savings Account (MSA) or Archer MSA are examples of other tax-favored plans that may be used with high-deductible health insurance polices.You can obtain more information about the tax benefits and restrictions of each of these types of plans from the administrator of your high-deductible health plan.
- Limited benefit plan: Some health insurance companies now offer a limited benefit plan for those who cannot afford regular health insurance. This type of plan package might include coverage for a certain number of physician visits, preventive care and for catastrophic illness. Premiums generally cost less (such as $50 to $100 per month). The important thing to consider is whether the coverage includes the type of treatment you need now or may need in the future.
- Short-term health insurance: Some insurance companies offer short-term health insurance, sometimes called a bridge policy. This type of policy is often limited to a specific period of time, such as six months. This type of coverage can be an indemnity or managed care policy. Short-term health insurance might be useful to someone who is taking a break between jobs and does not want to lose coverage and become subject to pre-existing condition waivers or exclusions in a new policy.
- Federally-Insured Plans: These plans are also called Guarantee Issue or HIPAA plans. They allow a person who has exhausted their COBRA coverage to purchase an individual health insurance plan without going through medical underwriting. However, the premium may be very expensive.
- State high-risk pools: Many states have high-risk pool insurance programs. These plans are for the "pool" or group of individuals in that state to whom private insurance companies will not sell individual policies for a variety of reasons. State-sponsored, nonprofit high-risk health pools allow individuals the option to purchase health insurance, although at a higher cost than individual plans.
- State risk pools vary greatly in benefits and eligibility requirements. They can be helpful to fill a temporary gap if you are denied health insurance coverage because of a medical condition. Organizations such as the Health Insurance Resource Center provide information about high-risk pools.
- Hospital indemnity coverage: This type of coverage pays a fixed amount per day for each day you are in the hospital for any reason up to a specified number of days. These policies are low cost but provide very limited coverage.
- Long-term care insurance: This insurance provides coverage for long-term health care services, whether at home or in a facility such as an assisted living facility or nursing home. Long-term care is usually not covered under employer health insurance plans or Medicare.
- "Catastrophic illness" coverage: Some health insurance plans allow you to purchase additional major medical or catastrophic illness coverage. This type of health policy typically has a high deductible requirement, but lower priced premiums. Additional coverage may be of interest if you have a chronic illness or your health insurance policy has a limited lifetime claim limit.
Finding a Health Insurance Plan to Meet Your Needs
Choosing the right health plan for your situation is very important. There are many health insurance plans to choose from and the quality of plans is varied. Your health plan will directly affect which medical providers will care for you and what kind of care you will receive. In addition, your plan will also affect when you receive medical care, how you will be cared for and how much the medical care will cost you.
If your health insurance is provided by your employer, and more than one plan is offered, compare the different plans to see which best meets your medical needs. The same is true if you are looking for individual insurance. Learn about a variety of health plans to select the one that will best meet your needs. Review and compare factors such as the following during the process of making your choice:
- Are the plan benefits rated highly by its members?
- Does the plan provide the health care benefits you need?
- Will the plan cover medical services provided by your current physician, hospital, lab, diagnostic facility and your other health care providers?
- Are covered medical services accessible to you?
- Does the plan cover the medications you are prescribed?
- Is the insurance company accredited and rated highly by industry standards?
- Is there an administrative process to appeal denials and access prescribed medical care?
Survivors also need answers to the following questions about a health plan:
- Is there a pre-existing condition exclusion period?
- Do physician appointments, treatments and prescribed drugs require prior approval from the insurance company?
- Does the plan exclude any coverage and/or specific medical services?
- What is the process for appealing a denial decision made by the insurer?
- What are the deductible and co-payment requirements for the plan?
- Is the plan affordable?
Evaluating a Health Insurance Plan
If you are applying for an individual health insurance plan, an independent insurance broker who works with multiple insurance companies will be able to provide information and recommendations based on their previous experiences with customer claims. Also, read the reports of independent insurance rating companies that are available on the Internet to find an insurer that is rated "excellent" or "superior." Talk with knowledgeable family and friends to find out about their insurance experiences and preferences.
Read the policy carefully so that you understand what the health plan will cover. Make certain that the plan you choose contains the features you need the most. If the health plan is a managed care plan, find out what the process would be if you wanted to use a medical provider that is not a member of the plan network.
During your research to find the health plan that will best meet your needs, find the answers to the following questions:
- What is the financial stability of the insurer?
- What is the insurance company's record of payment on insurance claims?
- How much will it cost for the desired health coverage?
- How do those who have coverage with the insurer rate the plan and service?
There are also statewide and national organizations that will help you evaluate health plan options:
- National Committee for Quality Assurance (NCQA) evaluates and rates managed care plans, and will provide you an Accreditation Status List at no charge and a Summary Report for a small fee.
- Health Insurance Resource Center (HIRC) can help if insurers determine that you are "not medically insurable." The HIRC will help you identify whether your state has sponsored a "risk pool" to provide health insurance coverage for people to whom private insurance companies will not sell individual policies.
- National Association of Insurance Commissioners (NAIC) is a good resource for insurance consumers. The work of the NAIC includes protecting the public interest, facilitating fair treatment of insurance consumers and supporting and improving state regulation of insurance. NAIC can also help you locate and research the high-risk insurance pool in your state.
As you research numerous health plans, avoid actually applying for insurance coverage with too many companies within a short time. Online companies that do business by taking your application to shop for and compare insurance rates will send your application to each insurance agency with whom they do business. In turn, each agency may then run your credit report. This means that your credit rating could be checked multiple times, and each check may reduce your credit score.
Getting the Best Individual Health Insurance Rates
Good communication with insurance representatives may help you get the best health rating and premium rate for your insurance policy. A rating determines whether there will be an additional charge added to the base premium cost because of an expectation of higher claim expenses due to any medical condition or a family history of medical conditions, or lifestyle activities that bring extra risk.
Although you may not be familiar with the MIB Group, Inc. Report (formerly known as the Medical Information Bureau), the medical and other information they have about you could affect your ability to get insurance coverage.
An association of more than 500 insurance companies from the United States and Canada, the MIB was created by insurance companies to protect themselves from fraud. They do this by sharing information about applicants for insurance policies with their member companies. The results of investigative reports (underwriting) done by the insurance companies are combined with the information in the MIB report and compared with your application for life, health or disability insurance.
An error in your MIB records could prevent you from obtaining insurance coverage, or affect how much you have to pay for a policy, so it is a good idea to check your MIB report to ensure that it is accurate. If you discover a mistake, you can request a correction from the MIB, as well as a reinvestigation by the insurer that provided the inaccurate information.
The following approach will help you get a good rating and the best price for your health insurance plan:
- Provide clear and complete health information. Consider how you state the information you provide. Keep in mind that incomplete answers can raise concerns on the part of the insurer. For example, instead of only stating that you have had cancer, you might want to offer more detailed information, such as when you were diagnosed with cancer and that you successfully completed treatment. If you are now considered to be free of cancer, share that information as well.
- Find out what your health rating with the insurer is and what it is based on. Keep in mind that the criteria, or standard of insurability by which you are judged should be objective and factual. Finding out how and why you are being ranked a certain way may allow you to provide more information that will improve your ranking and result in a lower premium.
- Compare insurers and insurance policies before you buy. Different insurance companies may view your health and the risk that you pose very differently. Ranking terms and definitions may vary between companies. Be certain that you understand how each insurance company views your health situation and how that will be reflected in your health insurance premium. An independent insurance agent may be able to provide this information and tell you how different insurance companies conduct their underwriting process.
Dealing with the Insurance Process and Claim Denials
Dealing with the insurance process can be challenging. Yet, there are steps that you can take to improve your success with the insurance system. If you have an active health insurance policy, it is important that you understand your coverage and keep records of your appointments, insurance authorizations and other communication (such as phone calls, emails or letters) with the insurer and the medical providers. This may seem like a lot of work, however, those records can become very important if your insurance company denies your claim and refuses to pay the medical provider.
If a claim that has been submitted to the insurer to cover medical expenses is denied, consider appealing the decision. Many insurance denials are the result of errors, such as a miscoded item on the claim form or a bill sent late to the insurer. An insurance company may reverse a denial decision and pay some portion or the full claim amount if the appropriate information is provided and the error corrected.
If an insurance claim is denied, you have the right to appeal the decision. Within the appeals process, there are usually second and third-level appeal options. In most states, the third level generally involves a review by an independent review organization. Check with your state insurance commission to learn about your rights to an external review of unfavorable appeals.
Knowing your rights to appeal and how to effectively submit an appeal, that includes the support of your medical provider, is critical to successfully using your health insurance. Start by getting a written letter from the insurer that states the exact reason your claim was denied. There may be variety of reasons for a denial decision so it is important to have the specific information documented to file an appeal. A simple error in the billing coding or a matter concerning coverage limits could result in the denial of a claim. However, the reason may be more complex, such as a determination about medical necessity or that a treatment is investigational or experimental.
Keep in mind that the insurer may have restrictions on the amount of time allowed to appeal denials. In addition, if a denied claim involved a new type of treatment, there may be a need for the physician to send an explanation of the treatment and its benefits to the insurer.
If you are not certain how to appeal a claim denial that may be unfair, there are people who will help you. The office of the Insurance Commissioner in your state is responsible for regulating the activities of insurers and health plans and dealing with consumer complaints. You can also talk with knowledgeable family and friends and/or contact someone who understands insurance matters, such as a local cancer organization, a patient advocate or an attorney.
Finding Other Health Coverage
If you are in danger of losing your individual or group health insurance and cannot afford to purchase another policy, check into other options. For example, if you are covered under COBRA, you may be eligible to convert your group coverage to an individual plan. Contact your insurance company to find out if you are entitled to a "conversion plan."
There are also health care assistance programs that will help people who have no health insurance, have only limited coverage or cannot afford to pay for the medical services they need. These programs may also be known as patient assistance, medical needs, reimbursement or compassionate care programs. Some of these assistance programs provide both medical services and financial help. Assistance might include finding a health care program you can work with, supporting your application for benefits or providing discounts on health care services.
Providers and resources for health care assistance include nonprofit organizations as well as local, state and federal government programs. Many nonprofit organizations will help you find health care assistance programs and apply for benefits at no charge. There is usually no need to pay for services that provide this type of referral or information.
The Bureau of Primary Health Care Web site, sponsored by the Health Resources and Services Administration (HRSA) Information Center provides online services, publications, information, resources, and referrals about health care services for people who cannot afford care and/or are medically underserved.
The LIVESTRONG SurvivorCare program offers assistance to all cancer survivors, including the person diagnosed, caregivers, family and friends. The program provides education, information about treatment options and new treatments in development, counseling services and assistance with financial, employment or insurance issues. To provide these services, LIVESTRONG SurvivorCare (www.LIVESTRONG.org/SurvivorCare or call 866-235-7205) has partnered with several organizations, including Patient Advocate Foundation and EmergingMed.
Also keep in mind that Federal and state benefit programs provide assistance for people with disabilities. Although you may not think of yourself as disabled, you may be eligible for disability benefits if your medical condition is severe enough to limit income and interfere with your ability to do work-related activities.
Look into federal and state benefit programs if you have concerns about how you can continue to support yourself because of cancer, its treatment or certain physical or emotional aftereffects. These programs include Social Security Disability Income, Supplemental Security Income, Medicare and Medicaid.
Other good sources of information about health care assistance programs may come from family members and friends, hospital social workers, case managers, or other medical team members, as well as representatives from cancer organizations.
This document was produced in collaboration with:
David S. Landay, Esq., author of Be Prepared: The Complete Financial, Legal and Practical Guide for Living with Cancer, HIV and Other Life-Challenging Conditions.
Barbara Ullman Schwerin, Esq.
Founding Director, Cancer Legal Resource Center, a joint program of the Disability Rights Legal Center and Loyola Law School, and former Adjunct Professor of Law at Loyola Law School
"A survival guide for the uninsured." Weston, Liz Pulham. MSN Money. 31 January 2007.
"Health Insurance/Access to Care." Agency for Healthcare Research and Quality. 26 January 2007.
"Choosing and Using a Health Plan." WebMD Public Information from the Department of Health and Human Services. 26 January 2007.
"Consumer Guide to Group Health Insurance." Consumer Information. National Association of Health Underwriters. 9 February 2007.
"Guide to Finding Health Insurance Coverage." Prepared by Families USA for Cover the Uninsured Week: Let's Get America Covered. 2 February 2007.
"Guide to Long-Term Care (LTC) Insurance." America's Health Insurance Plans. 26 January 2007.
"Health insurance for medically-uninsurable individuals." Health Insurance Resource Center. 31 January 2007.
"Health insurance reform for consumers," Centers for Medicare and Medicaid Services,. Retrieved 9/30/2009 from http://www.cms.hhs.gov/healthinsreformforconsume
"HSA Primer for Employees/Individuals/Families." Information Strategies, Inc.29 January 2007.
"Insurance Questions and Programs Offered to Cancer Survivors." Beyond the Cure. The National Cancer Society. 22 May 2006.
Landay, David S. Be Prepared: The Complete Financial, Legal and Practical Guide to Living with Cancer, HIV and Other Life-Challenging Conditions. New York: St. Martin's Press, 1998.
"Medical Insurance and Financial Assistance for the Cancer Patient." American Cancer Society. 22 May 2006.
"9 keys to choosing the right health plan." MSN Money: Insure Your Health. 31 January 2007.
"16 ways to slash your insurance rates." MSN Money: Insure Your Health. 31 January 2007.
"The Health Insurance Portability and Accountability Act (HIPAA)." Employee Benefits Security Administration Fact Sheet.." U.S. Department of Labor. 6 February 2007.
"What is an HSA?" A complete guide to Health Savings Accounts for families, individuals and employers. 29 January 2007.
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Individual and Group Health Insurance: Suggestions
The suggestions that follow are based on the information presented in the Detailed Information document. They are meant to help you take what you learn and apply the information to your own needs. This information is not intended nor should it be interpreted as providing professional medical, legal and financial advice. You should consult a trained professional for more information.
Assess your current health care coverage. If you have no health insurance at this time, a review of your medical needs will help you identify the type of insurance coverage to get.
- Make certain the plan you select will cover your health care providers, including doctors, hospitals, diagnostic services and therapists.
- Find out if your prescribed medications will be covered at the level that you need.
Find out what each health insurance plan covers and what it does not. Read the plan to see what health care services are included and are not:
- Make a list of your current and projected health care needs for services and treatments.
- Review existing health insurance plans, as well as your current medical needs to decide whether you have the right type of health coverage.
- Define the co-payment and deductible charges that the health plan may require.
- Find out if the services of your current physician or health care provider will be covered under the health plan.
- Find out which treatments are covered and if prescribed long-term follow-up care is included.
- Consider how much you will have to pay for services, including physician visits, lab tests and prescription medications.
- Identify whether the insurance plan will cover expenses related to your health care, such as lodging, meals and transportation.
- Find out if the insurer is billed directly by the medical providers or whether you must first make the payment and later receive reimbursement from the insurance company.
Identify specific prescription medication coverage provided by the health plan. Find out:
- What medications are covered by the plan (generic and brand coverage)?
- Are the medications you currently take covered?
- How much you will have to pay if your medications are not covered?
- Will there be a limit to how much money the insurer will pay for medications?
Decide what health plan services will meet your needs. In addition to follow-up care for cancer, consider possible future events in your life, such as:
- Plans to have a baby or adopt
- Plans to retire in the near future
- Chronic health problems or disabilities that you or family may have
- Specific needs of family members
Keep in mind additional factors, such as:
- Preference for alternative treatments, such as acupuncture, massage and chiropractic care
- Need for physical therapy and other rehabilitation services
- Options for home health, nursing home and hospice care
- Availability of screening and diagnostic testing services
- Interest in health education programs, such as stop smoking or healthy heart classes
- Physician, health care provider or facility preferences
As you research different health insurance plans, find out if the plan covers payment for all or a portion of the following medical items and services:
- Follow-up care, including exams, scans, x-rays and lab services
- Prescription medications
- Emergency services, including ambulance transport
- Routine physicals
- Eye exams, glasses and contacts
- Hearing exams and hearing aids
- Dental exams and treatments
Other considerations for plan coverage include:
- Programs for specific medical conditions, such as asthma, diabetes or heart
- Care giver services, such as respite care and social services
- Wellness programs and classes
Research the quality and record of health plans you consider. Seek information from sources, such as the following:
- Federal and state agencies regulate many managed care plans.
- State Departments of Health and insurance commissions regulate indemnity plans.
- National organizations review and accredit health plans.
- Many insurers have satisfaction survey results (available upon request) that come from follow up with past and current members about their personal experiences with their health plans.
Investigate claim denials and consider appealing a denial decision. If your insurer denies a claim, you have the right to appeal. Keep in mind that within the appeals process, there are usually second and third-level appeal options. The third level usually involves a review by an independent review organization. If you believe your health services claim should be covered under your insurance plan:
- Get a written copy of the reason the claim was denied from the insurer.
- Review your policy to see if the treatment or procedure is covered.
- Communicate with the insurer to clarify questions and policies and keep records of your correspondence and conversations.
- Act within the timeframe the insurer allows for appeals of claims denials.
- Follow up with the medical provider to ensure that required treatment information and bills have been submitted to the insurer in a timely manner.
- Collect relevant information and advocate for yourself.
- Take advantage of all your appeal options.
If you believe that an unfair claim denial has been made, contact an advocacy organization for assistance, such as Patient Advocate Foundation, Cancer Legal Resource Center or your state insurance commissioner's office.
If you are in danger of losing your individual or group health insurance and cannot afford to purchase another policy, check into other options. The Bureau of Primary Health Care Web site, sponsored by the Health Resources and Services Administration (HRSA) Information Center provides online services, publications, information, resources, and referrals about health care services for people who cannot afford care and/or are medically underserved.
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