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Insurance
Health Insurance Basics
By the Virginia Bureau of Insurance
Consider the following features when comparing health care options. While this list of features is not an all-inclusive list, it is intended to provide you with general guidance and important references.
Find out about the company. The Bureau of Insurance can tell you whether a company is licensed and in good standing to do business in Virginia. However, the Bureau does not rate or recommend particular insurance companies or managed care health insurance plans.
When selecting an insurance company, it is wise to check on a company's rating. Several organizations publish insurance company ratings. The ratings, including those listed below, may be available in your local library or on the internet. Companies are rated on a number of elements, such as financial data (including assets and liabilities), management operations, and the company's history. You may also wish to review a company's stock analysis reports.
Insurance Company Rating Services:
Note: There may be a cost associated with obtaining rating information. Before purchasing insurance, it is important to verify whether a company is an authorized insurer or managed care health insurance plan in Virginia. The Virginia Department of Health also offers a listing of licensed Managed Care Health Insurance Plans.
The National Committee for Quality Assurance (NCQA), an independent organization that assesses and reports on health plan quality, can provide information about the quality of care provided by an HMO. The NCQA can be contacted at 1-888-275-7585 or online at www.ncqa.org. Be sure to evaluate carefully whether the HMO operates in a service area that is accessible to you and for which you are eligible based on your residence or place of employment.
What are my out-of-pocket costs?
Become familiar with any amount you will be required to pay when you obtain medical services under your policy or plan. Know your policy or plan deductible, co-payment, coinsurance amount, premiums, and any plan limitations or maximums. Review carefully the policy or plan features concerning premium increases.
What provisions might affect my coverage?
Coordination of Benefits - Many health insurance policies and managed care plans coordinate benefits with other plans when other coverage is involved. Familiarize yourself with how your claims will be paid when you have other health insurance coverage or another managed care health insurance plan. Provider Networks - In managed care plans, with some exceptions, you are required to use network providers and facilities. Find out if plan providers are conveniently located; how you obtain referrals; the circumstances under which you obtain services from a provider outside of the network and any associated fees; and the extent to which your plan will cover care obtained outside of the network when you are traveling.
Renewal and Premium Increase - This provision explains when and under what circumstances your insurance company can renew your policy or increase your premiums.
Conversion Privileges - This provision allows you to convert coverage to a different insurance plan when you lose eligibility, without a medical examination to prove good health.
What If I Lose My Group Insurance Coverage?
There are a number of situations that may result in losing group health insurance or managed care coverage. Generally, when this happens, there are options to continue or convert your group
insurance coverage: COBRA Under the Consolidated Omnibus Budget Reconciliation Act
(COBRA), group health plans sponsored by employers with 20 or more employees are required to offer continuation of coverage for you and your dependents for at least 18 months. This period may be extended, depending upon the qualifying event causing the group coverage to end. If you wish to continue your group coverage under COBRA, you must notify your employer within 60 days of receiving notice of your COBRA eligibility. You must also pay the entire premium on a monthly basis, as well as an administrative fee.
WARNING: COBRA is complicated. Your employer's Human Resources office should have a booklet that explains in detail how COBRA works. This booklet may also be obtained from the Bureau of Insurance. COBRA is a federal act and the U.S. Department of Labor governs COBRA issues. Contact the Department of Labor at www.dol.gov or call 1-866-487-2365 (TTY 1-877-889-5627).
The Centers for Medicare & Medicaid Services or "CMS", formerly known as the Health Care Financing Administration or "HCFA", has created a website for COBRA continuation of coverage as it applies to group health plans sponsored by state and local government employers (title XXII of the Public Health Service Act; 42 U.S.C. 300bb-1 through 300bb-8). The website is designed to assist qualified beneficiaries, state and local government employers and group health plan administrators in understanding their rights and responsibilities with respect to public sector COBRA continuation coverage. The website may be directly accessed at www.cms.hhs.gov/hipaa/hipaa1/cobra.
Conversion or Continuation
Traditional group health insurance policies issued under Virginia law include either a conversion provision or a 90-day continuation period. (HMO plans must offer the conversion option, but do not have to offer a continuation option). The conversion provision states that an insured group member who is leaving the group has the right to convert to an individual health insurance policy or plan from the group insurer without presenting evidence of insurability. The conversion application for the policy has to be made to the insurer within 31 days after termination.
The continuation provision requires application for the extended coverage to be made to the group policyholder prior to termination. The certificate of insurance issued to each person under the group policy will indicate which option is available.
There may be other options available to you as well, depending upon your individual circumstances:
- You may be able to obtain other coverage in accordance with requirements enacted to comply with the Health Insurance Portability and Accountability Act (HIPAA), (a further explanation of HIPAA follows below).
- You may consider purchasing a short-term health insurance policy if you are temporarily between jobs. NOTE: the purchase of this policy will negate your HIPAA portability qualifications.
- You may secure health insurance through an association. READ YOUR CERTIFICATE or EOC CAREFULLY to evaluate the options available to you.
The Health Insurance Portability and Health Insurance Portability and Accountability Act (HIPAA)
A federal law called the Health Insurance Portability and Accountability Act of 1996 (HIPAA) made important changes regarding health insurance in the United States. The Virginia General Assembly passed laws implementing the requirements of HIPAA. These laws provide you with important protections. In some cases, the Virginia laws already met or exceeded these new federal standards prior to the implementation of HIPAA.
HIPAA and the laws enacted in Virginia to implement it may assist you in the following situations:
- Increasing your ability to get health coverage for yourself and your dependents if you start a new job;
- Lessening your chance of losing existing health care coverage;
- Helping you maintain continuous health coverage for yourself and your dependents when you change jobs; and
- Helping you buy health insurance coverage if you lose coverage under an employer's group health plan and have no other health coverage available.
HIPAA and Virginia laws enacted to implement HIPAA provide the following specific protections:
- Limit the use of pre-existing condition exclusions;
- Prohibit group health plans from discriminating by denying you coverage or charging you more for coverage based on your or your dependent's past or present health conditions;
- Guarantee certain small employers, and certain individuals who lose job-related coverage, the right to purchase health insurance; and
- Guarantee, in most cases, that employers or individuals who purchase health insurance can renew coverage regardless of any health conditions of individuals covered by the insurance.
HIPAA (and the state laws that implement it) is complex. Because of the complexity of these laws and how they may apply to your situation, we encourage you to call the Bureau of Insurance to discuss the protections available to you under HIPAA and Virginia law.
Making A Health Insurance Claim
Things to do before you file a claim:
- Review your policy, employee handbook, benefit booklet or EOC carefully to be sure the service in question is covered.
- Follow any rules, including pre-certification requirements and use of network providers, if applicable.
- Find out if your provider submits the claim for you or if you need to do it.
How to submit a claim properly:
- If you need to submit a claim, review the information to be sure it is complete and correct.
- Include your policy number and other identifying information.
- Submit the claim promptly following the accident or illness.
- Send the claim to the right address.
- Keep copies of all documentation for future reference.
Allow reasonable time for the company to process the claim. The company should inform you if it needs any additional information to complete the claim.
If your claim is paid:
- If you assigned benefits to the provider, the payment will go directly to the provider. You will pay any deductibles, coinsurance or other cost-sharing amounts.
- If you did not assign benefits, the payment will go directly to you, and you will need to pay your providers for the entire amount due them.
If your claim is denied:
- The reason for denial should be stated on your explanation of benefits.
- If you disagree with the reason for denial, review the policy, EOC, employee booklet or benefit booklet for information on review of the claims decision.
- The company should answer any questions you may have.
- If you cannot get the problem resolved by dealing directly with the company, the Bureau of Insurance will assist you with claims and complaints.
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