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| Protecting Your Family and Property |
If you think certain charges are incorrect or if you were charged for a service you didn’t receive, don’t hesitate asking a provider about the cost of tests or services. You can take the following actions if concerned about a fee or charge:
Filing Claims
Insurance companies and HMOs are required by state law to pay claims promptly and fairly or otherwise be subjected to penalties. This prompt-payment law does not apply to self-funded ERISA plans.
If a carrier denies your claim for benefits, there must be a written explanation. If unsatisfied, you can ask to see the policy language used to deny the claim. If you decide to dispute the claim, make sure you provide the insurer with all of the details about the treatment, the condition and any special qualifications applicable. Also, ask the provider to send a letter explaining anything unusual about the procedure or the amount charged.
Losing Coverage
If you have individual coverage through a licensed insurance company that dissolves, a state guaranty association covers valid claims up to a certain amount; however, the guaranty association does not cover claims against HMOs, MEWAs, valid self-funded ERISA health benefit plans and fraternal benefit societies. HMOs are required to keep cash and securities deposited with the state to pay claims in these cases. If an HMO is unable to pay claims, the State Insurance Commissioner has the authority to assign affected members to another local licensed HMO.
Individual health plans covering hospital, medical and surgical expenses are “guaranteed renewable,” which means renewal cannot be denied arbitrarily even because of health-related factors. However, the plan can cancel your coverage for several reasons, including but not limited to the following:
If you lose coverage from a change in marital status, you are entitled to your own individual policy and do not have to prove you’re in good health to receive it. In addition, the death of an insured spouse does not necessarily terminate coverage because the surviving spouse becomes the insured.
Those on a group health plan can lose coverage for several reasons, including the following:
If coverage is terminated for reasons of death, retirement or divorce, continuation of the group coverage is required for certain dependents for up to three years. Qualifying dependents are those that were covered by the group policy for one year or are less than 1 year old. Continuation of coverage ends before the three-year period if dependents obtain new coverage, premiums are not paid or the group policy is terminated.
COBRA Protection
Under a federal law called COBRA (Consolidated Omnibus Budget Reconciliation Act), you may be able to continue coverage for a limited time if you lose it for some types of termination and retirement; however, the former employer no longer will contribute toward the premium.
Individuals eligible for COBRA previously held a health plan through a company with 20 or more employees unless it was sponsored by the federal government or certain church-related organizations. COBRA generally only applies to employees who lose coverage because of reduced work hours or losing the job for reasons other than “gross misconduct.” COBRA extends coverage for an individual for up to 18 months and for a spouse and any dependent children for up to 36 months. COBRA also allows dependents to continue coverage if an employee is entitled to Medicare, divorces or dies.
- Get a second opinion if surgery is involved.
- Ask questions about billings you do not understand. If the explanation doesn’t make sense, check with your plan.
- Request an itemized bill and review it. Make sure the provider used the proper treatment or procedure code. If not, the wrong amount can be listed.
- Check with your plan to see if the treatment is what you really got or, if the cost estimate is within the “usual and customary” range, keep a record of everyone you talk to and when.
- Use your county medical association, which has grievance committees that accept complaints against physicians or providers and intermediate fee disputes.
Filing Claims
Insurance companies and HMOs are required by state law to pay claims promptly and fairly or otherwise be subjected to penalties. This prompt-payment law does not apply to self-funded ERISA plans.
If a carrier denies your claim for benefits, there must be a written explanation. If unsatisfied, you can ask to see the policy language used to deny the claim. If you decide to dispute the claim, make sure you provide the insurer with all of the details about the treatment, the condition and any special qualifications applicable. Also, ask the provider to send a letter explaining anything unusual about the procedure or the amount charged.
Losing Coverage
If you have individual coverage through a licensed insurance company that dissolves, a state guaranty association covers valid claims up to a certain amount; however, the guaranty association does not cover claims against HMOs, MEWAs, valid self-funded ERISA health benefit plans and fraternal benefit societies. HMOs are required to keep cash and securities deposited with the state to pay claims in these cases. If an HMO is unable to pay claims, the State Insurance Commissioner has the authority to assign affected members to another local licensed HMO.
Individual health plans covering hospital, medical and surgical expenses are “guaranteed renewable,” which means renewal cannot be denied arbitrarily even because of health-related factors. However, the plan can cancel your coverage for several reasons, including but not limited to the following:
- The plan is dropped for all policyholders. In this circumstance, the carrier must offer policyholders losing coverage the right to purchase another plan the carrier offers. If a carrier withdraws from the Texas market entirely, it cannot reenter for five years.
- You knowingly misrepresent personal information in your application, file a false claim or commit other fraud against the carrier.
- You do not pay your premiums.
- You are late on payment of premiums on an individual policy. Some carriers may accept late payments, but many require reapplication and reconsideration of your health history before deciding if your coverage will be reinstated. Note that reinstated coverage repays only health expenses from accidents that occurred after reinstatement and expenses from illnesses beginning more than 10 days after reinstatement. With a policy reinstatement, the carrier may attach riders that exclude certain coverage on a temporary or even permanent basis.
If you lose coverage from a change in marital status, you are entitled to your own individual policy and do not have to prove you’re in good health to receive it. In addition, the death of an insured spouse does not necessarily terminate coverage because the surviving spouse becomes the insured.
Those on a group health plan can lose coverage for several reasons, including the following:
- Reduction to part-time status
- Terminating membership in the association or group sponsoring the plan
- Losing your job
If coverage is terminated for reasons of death, retirement or divorce, continuation of the group coverage is required for certain dependents for up to three years. Qualifying dependents are those that were covered by the group policy for one year or are less than 1 year old. Continuation of coverage ends before the three-year period if dependents obtain new coverage, premiums are not paid or the group policy is terminated.
COBRA Protection
Under a federal law called COBRA (Consolidated Omnibus Budget Reconciliation Act), you may be able to continue coverage for a limited time if you lose it for some types of termination and retirement; however, the former employer no longer will contribute toward the premium.
Individuals eligible for COBRA previously held a health plan through a company with 20 or more employees unless it was sponsored by the federal government or certain church-related organizations. COBRA generally only applies to employees who lose coverage because of reduced work hours or losing the job for reasons other than “gross misconduct.” COBRA extends coverage for an individual for up to 18 months and for a spouse and any dependent children for up to 36 months. COBRA also allows dependents to continue coverage if an employee is entitled to Medicare, divorces or dies.
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