Legal Issues and Insurance Coverage

Not all employers are required to offer health benefits to all employees. However, if you are offered group health coverage, you have rights under federal and state laws, including:

• Nondiscrimination
  Your eligibility for group coverage does not depend on how healthy you are now or have been in the past.
• Coverage for pre-existing conditions
  Some group health-insurance plans may temporarily exclude a certain health condition. In most cases, exclusion is limited to 12 months.
• Consolidated Omnibus Budget Reconciliation Act (COBRA)
  This federal law allows you or your dependents to remain in your group plan for up to 18 to 36 months after you terminate employment. When you accept COBRA coverage, you are responsible for paying the entire premium.
• Health Insurance Portability and Accountability Act (HIPAA)
  HIPAA protects the health coverage of individuals who have a preexisting health condition. Before this law was passed, individuals with a health condition could be excluded from group health insurance with a new employer.

If your employer provides health insurance, the following rules relating to HIPAA apply:

• HIPAA limits exclusions for preexisting health conditions (a condition for which medical advice, diagnosis or treatment was received or recommended in the six months prior to enrollment in a new health plan).
• Pregnancy or the health condition of a newborn child are exempt from preexisting condition exclusions. Any genetic information, in the absence of a diagnosis, is not considered a preexisting condition.
• The maximum duration of the preexisting-condition exclusion is 12 months after the enrollment date.
• If you were covered by another health-insurance plan and coverage did not lapse, your new plan must reduce the preexisting exclusion period by the number of days that you were covered under your old plan. You will have to provide coverage documentation. If you have been covered by insurance for the past year without a break in coverage, the preexisting exclusion does not apply.

Making the Most of Your Health Insurance

Throughout your life you will need to understand the ins and outs of your insurance policy. Here are some specific questions you should be able to answer:

• Which doctors and hospitals are included in your provider network?
• When do you have to get authorization prior to treatment?
• Does your prescription coverage include name-brand or generic drugs, and how much of the cost is covered?
• What inpatient and outpatient treatments are covered?
• Does your policy have a lifetime maximum or 'cap' for treatment?
• Does your insurance cover any ancillary expenses (lodging, meals or transportation)?
• Does your insurance operate on a reimbursement basis, or will the providers send invoices?
• Who is your contact person at the insurance company? Whom should you contact regarding denials?

To be an effective advocate for yourself, you should keep the following information for your records:

• Keep a copy of everything related to your medical treatment. This includes all authorization forms, explanation of benefits (EOB) forms, all communication with the insurance company and any communication regarding bills and payments.
• If your provider is responsible for sending invoices, ensure that this happens in a timely manner. You may have to verify with the doctor's office that this has happened a week or two after the appointment.
• Compare your dates and services provided to the EOB you receive.

If your insurance company denies a claim, investigate the reason. Many denials are due to errors. For example, the doctor's office may have miscoded an item, or the bill may have been sent out late. If you see a problem, contact the provider's billing office or the insurance company. When the mistake is corrected, the insurance company will reverse its denial.

Understand your insurance coverage and track your appointments, authorizations, communications and EOBs. The paperwork may seem overwhelming, but it's essential for battling erroneous denials.

If you receive a denial that isn't the result of a billing error, you may still want to appeal the decision. Make sure you know the insurance company's time frame for appeal, and take the following steps. If you need help, contact the Patient Advocate Foundation or a similar organization. Steps to take:

• Obtain a written copy of the reason for the denial. Denials occur for a variety of reasons, but typically are triggered by procedures the insurance company deems outside the standard of care.
• Check your insurance guide. If the guide states the procedure is covered, contact the insurance company to clarify.
• If the insurance denial states "not standard of care or experimental," as the reason for denial, ask your doctor to send an explanation of the treatment to the insurance company and follow up yourself. Insurance companies are not always aware of the latest treatment procedures. Your advocacy will assist future patients.

If your insurance company persists in issuing what you consider an unjust denial, consider contacting a third party, such as the Patient Advocate Foundation or your state insurance commissioner.

Understanding your health-insurance policy may be a challenge. If you have questions, contact your state insurance commissioner's office or the U.S. Department of Labor, which regulates health plans offered by many large employers. In addition, you can get a free review of your policy by contacting the Patient Advocate Foundation at 1-800-532-5274.