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| Protecting Your Family and Property |
Federally Mandated Benefits
Beyond the benefits required by state law, health plans must follow federal laws in regard to offering coverage for maternity and newborn and mastectomy services.
— Maternity and Newborn Coverage
No carrier may deny benefits for services related to a pregnancy on the grounds that it is a “pre-existing condition.” A group health plan with more than 15 employees must provide for minimum hospital stays for the delivering mother. For a natural birth or “uncomplicated vaginal delivery,” the insured is guaranteed a minimum of 48 hours. The minimum stay for an uncomplicated cesarean birth is 96 hours.
In most cases, management of a difficult birth is covered by plans with maternity benefits and is not considered a “complication of pregnancy.” Complications that may not be covered include miscarriages or nonelective cesarean births, for which obtaining a “complications of pregnancy” benefit may help if your plan does not have extensive maternity benefits.
A carrier cannot exclude or limit initial coverage for a newborn child because of premature birth, accident, illness or congenital medical conditions, including the need for reconstructive surgery of craniofacial abnormalities on children under 18 who have been covered continually by a health plan. Furthermore, all plans must provide automatic coverage for newborn children for the first 31 days, after which the insured parent must notify the carrier about continuing coverage.
— Mastectomy Coverage
Plans that offer mastectomy coverage also must provide for reconstructive surgery for both breasts, regardless of which was affected by the disease if such reconstruction is needed to produce a symmetrical appearance. This coverage is subject to the deductibles, copayments and coinsurance consistent with the plan. The benefit also must cover prosthesis and treatment of complications at all stages of the surgery, including lymphedemas.
Limitations of Coverage
Insurance carriers can deny payment or continuation of any treatment deemed not “medically necessary.” Under Texas state law, health plans must have procedures in place wherein, before any nonemergency medical procedures is approved, an appropriate physician or other health-care provider performs a “utilization review” using objective, medically valid criteria (compatible with established health-care principles and flexible enough to allow deviation from standard guidelines on a case-by-case basis) to approve or deny those requested services or treatments. Any decision denying treatment must have a specific and valid medical reason.
For unresolved complaints about a utilization review for all plans (except self-funded), you can file a complaint with TDI. For complaints about self-funded plans, contact the U.S. Department of Labor’s Pension and Welfare Benefits Administration at (972) 850-4500.
Understand that “approval of treatment” is not the same as “approval for payment.” Even if you are treated, you still may need to file a claim for reimbursement. Carriers can refuse payment for portions of approved treatment if deemed “unnecessary expenses.” To reduce the chance of a claims problem, read your policy or benefits booklet carefully and make sure you are meeting the plan’s requirements and keep copies of all correspondence regarding your treatment and billing with the insurance company and health care provider.
Pre-existing Conditions and Waiting Periods
People with medical problems currently or in the recent past may qualify as having a “pre-existing condition.” Carriers usually define a pre-existing condition as one for which you have received medical advice, diagnosis or treatment or one with symptoms likely to cause you to seek diagnosis or care during a period of time before the plan takes effect. To determine pre-existing conditions, typically individual plans consider applicants’ medical history for the previous five years, employer-sponsored plans consider the previous six months and other group plans look at the previous 12 months.
Legally, new applicants must disclose any pre-existing conditions within the consideration period specified on the health-plan application. Failure to do so can jeopardize future claims or render the policy invalid. Furthermore, an individual-plan carrier may decline coverage because of a pre-existing condition or it may insist on a special policy “rider” that excludes treatment for that particular condition. Group carriers may not insist on a pre-existing-condition exclusion rider, but most plans do require new members to wait a period of time—months or sometimes years—before it pays benefits for treatment related to that condition.
Some plans even require a standard waiting period before new members are eligible to receive any benefits regardless of pre-existing conditions. If this is the case, your “pre-existing condition” wait begins with the start of the insurance. For example, if your plan has a waiting period of three months for any benefits and a pre-existing-condition waiting period of one year, new members are eligible to receive benefits for pre-existing conditions nine months after the initial waiting period. HMOs have an “affiliation period” that works similarly to a waiting period for pre-existing conditions in indemnity plans; however, it may not exceed 90 days.
Beyond the benefits required by state law, health plans must follow federal laws in regard to offering coverage for maternity and newborn and mastectomy services.
— Maternity and Newborn Coverage
No carrier may deny benefits for services related to a pregnancy on the grounds that it is a “pre-existing condition.” A group health plan with more than 15 employees must provide for minimum hospital stays for the delivering mother. For a natural birth or “uncomplicated vaginal delivery,” the insured is guaranteed a minimum of 48 hours. The minimum stay for an uncomplicated cesarean birth is 96 hours.
In most cases, management of a difficult birth is covered by plans with maternity benefits and is not considered a “complication of pregnancy.” Complications that may not be covered include miscarriages or nonelective cesarean births, for which obtaining a “complications of pregnancy” benefit may help if your plan does not have extensive maternity benefits.
A carrier cannot exclude or limit initial coverage for a newborn child because of premature birth, accident, illness or congenital medical conditions, including the need for reconstructive surgery of craniofacial abnormalities on children under 18 who have been covered continually by a health plan. Furthermore, all plans must provide automatic coverage for newborn children for the first 31 days, after which the insured parent must notify the carrier about continuing coverage.
— Mastectomy Coverage
Plans that offer mastectomy coverage also must provide for reconstructive surgery for both breasts, regardless of which was affected by the disease if such reconstruction is needed to produce a symmetrical appearance. This coverage is subject to the deductibles, copayments and coinsurance consistent with the plan. The benefit also must cover prosthesis and treatment of complications at all stages of the surgery, including lymphedemas.
Limitations of Coverage
Insurance carriers can deny payment or continuation of any treatment deemed not “medically necessary.” Under Texas state law, health plans must have procedures in place wherein, before any nonemergency medical procedures is approved, an appropriate physician or other health-care provider performs a “utilization review” using objective, medically valid criteria (compatible with established health-care principles and flexible enough to allow deviation from standard guidelines on a case-by-case basis) to approve or deny those requested services or treatments. Any decision denying treatment must have a specific and valid medical reason.
For unresolved complaints about a utilization review for all plans (except self-funded), you can file a complaint with TDI. For complaints about self-funded plans, contact the U.S. Department of Labor’s Pension and Welfare Benefits Administration at (972) 850-4500.
Understand that “approval of treatment” is not the same as “approval for payment.” Even if you are treated, you still may need to file a claim for reimbursement. Carriers can refuse payment for portions of approved treatment if deemed “unnecessary expenses.” To reduce the chance of a claims problem, read your policy or benefits booklet carefully and make sure you are meeting the plan’s requirements and keep copies of all correspondence regarding your treatment and billing with the insurance company and health care provider.
Pre-existing Conditions and Waiting Periods
People with medical problems currently or in the recent past may qualify as having a “pre-existing condition.” Carriers usually define a pre-existing condition as one for which you have received medical advice, diagnosis or treatment or one with symptoms likely to cause you to seek diagnosis or care during a period of time before the plan takes effect. To determine pre-existing conditions, typically individual plans consider applicants’ medical history for the previous five years, employer-sponsored plans consider the previous six months and other group plans look at the previous 12 months.
Legally, new applicants must disclose any pre-existing conditions within the consideration period specified on the health-plan application. Failure to do so can jeopardize future claims or render the policy invalid. Furthermore, an individual-plan carrier may decline coverage because of a pre-existing condition or it may insist on a special policy “rider” that excludes treatment for that particular condition. Group carriers may not insist on a pre-existing-condition exclusion rider, but most plans do require new members to wait a period of time—months or sometimes years—before it pays benefits for treatment related to that condition.
Some plans even require a standard waiting period before new members are eligible to receive any benefits regardless of pre-existing conditions. If this is the case, your “pre-existing condition” wait begins with the start of the insurance. For example, if your plan has a waiting period of three months for any benefits and a pre-existing-condition waiting period of one year, new members are eligible to receive benefits for pre-existing conditions nine months after the initial waiting period. HMOs have an “affiliation period” that works similarly to a waiting period for pre-existing conditions in indemnity plans; however, it may not exceed 90 days.
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