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Insurance
Frequently Asked Questions
By the Virginia Bureau of Insurance
General Health Insurance
Where can I obtain health insurance?
Insurance agents and companies are listed alphabetically and by location in the yellow pages of your telephone directory. The Bureau of Insurance also provides a listing of carriers licensed to write health insurance and licensed HMOs in Virginia. These listings may be obtained by calling the Bureau of Insurance, or visiting the Bureau's website. Click on "Consumer" and "Want Information About a Company?" Insurance premiums can vary substantially from company to company so it usually pays to check with several companies before making a final choice.
I had a serious health condition that appears to be stabilized; however, I am having difficulty finding an insurance company that will accept me for coverage. I am not eligible for guaranteed coverage under HIPAA. What options are available to me?
Each insurance carrier has its own underwriting guidelines. The type of condition and when/how it was treated will factor into how the insurance company will respond. Contact several insurance
companies, then compare options available to you. If none of the options suit you, you may contact Anthem Health Plans of Virginia, Inc. (formerly TRIGON) at 1-800-334-7676 or Carefirst Blue Cross Blue Shield at 1-800-544-8703. You may qualify for an open enrollment program where you cannot be denied insurance. However, there may be a waiting period for pre-existing conditions. There is no risk pool in Virginia. Therefore, the Open Enrollment product may be the only way for you to secure insurance if you can not get it anywhere else.
I have changed my mind and do not wish to keep the individual health insurance policy that I just received. May I get a refund?
Yes. According to Virginia law, if you are not satisfied with your individual traditional health insurance policy for any reason, you may return it to the company within 10 days of the date you received it and the premium you paid will be promptly refunded. This law does not apply, however, to individual HMO plans.
My insurance company pays 80% of charges. My provider charged $4,000 for a medical service, but the insurance company paid only $2,800. Why didn't they pay the full 80%?
Companies often establish allowable charges for certain procedures and services. These charges may be based on a "usual, customary and reasonable" (UCR) schedule, or they may be based on other criteria established by the company. It appears that your company paid 80% of the allowable or UCR charge established by the company for your medical procedure.
Providers can appeal to companies if a procedure or service was especially difficult, or other circumstances necessitated a charge exceeding the allowable or UCR charge. Your policy, certificate, EOC or benefit booklet provides information concerning appeals or requests for reconsideration of payments.
I have just received notice that my health insurance premium is increasing. I have not had any claims. How is my company justified in raising my rate?
Premium rates are calculated based on the pooling of a large number of similar risks. The claim experience of the pool, as a whole, is used to determine premium rates.
Does the Virginia Bureau of Insurance regulate all health insurance?
Group and individual health insurance plans issued and delivered in Virginia are subject to regulation by the Bureau of Insurance. Most group plans issued to associations or trusts located outside of Virginia, however, are governed by the state in which the policy was issued for delivery, regardless of whether individuals covered under these plans reside in Virginia. Also, self-insured (or self-funded) plans are regulated by the federal government.
Does the Bureau of Insurance regulate health insurance rates?
The Bureau of Insurance approves premium rates for individual health insurance policies. In all cases, rates must be applied fairly and reasonably.
My insurance company has rescinded my health insurance policy. What does this mean?
The insurer has voided coverage. Recision usually occurs as a result of incomplete or inaccurate information submitted on the application, or an omission of information that is pertinent to the underwriting of the policy.
What is a drug formulary?
Many plans or policies establish a list of prescription drugs, which the plan considers medically appropriate and cost effective. The plan will provide coverage for only those prescription drugs named in the list.
However, your doctor may present medical evidence to the insurer to obtain an exception that will allow coverage for a prescription drug not routinely covered by the plan.
Group Health Insurance
I will be leaving my job in a couple of weeks and I am worried about my health insurance. Is there any way I can keep my group insurance coverage?
If you are leaving a job, The Federal Consolidated Omnibus Budget Reconciliation Act (COBRA) requires group health plans sponsored by employers with 20 or more employees to offer continuation of coverage for you and your dependents for 18 months or longer, depending on the qualifying event. You would be responsible for the entire premium, both the portion you paid as an employee and the employer's contribution, as well as an administrative fee.
You may also be able to continue the group coverage for an additional 90 days. Or, you may be able to convert your group coverage to an individual coverage. Your group certificate or EOC will
indicate the options available to you.
Why are premiums on a conversion policy so expensive?
Conversion is made without evidence of insurability and, therefore must cover those who would otherwise be uninsurable. Because the claims experience for these types of policies is generally much higher, substantial premiums are often required to cover the risk.
I heard about a law that allows you to take your medical coverage with you when you change jobs. Is this true?
Under the Health Insurance Portability and Accountability Act of 1996 (HIPAA), you do not actually take your exact plan of health benefits with you, but you are credited with the time you were covered under your previous group policy under your new benefit plan. To receive this credit, you must meet the criteria for an "eligible individual." Virginia law provides for credit towards any preexisting condition waiting period in your new benefit plan for the amount of time you were covered by your prior group or individual health plan if you do not have greater than a 63-day break in coverage. Also, the new carrier must offer you the insurance coverage without your having to medically qualify for the coverage as long as you are an "eligible individual." For a more detailed explanation concerning HIPAA and the criteria for an "eligible individual," please contact the Bureau of Insurance.
I am having a problem with my employer's self-funded (self-insured) health plan. Can you help?
Self-insured group health plans (or self-funded plans) are set up by employers to pay the health claims of its employees. The employer assumes the risk of providing the benefits and paying the claims. A self-insured plan is not subject to the regulatory authority of the Bureau of Insurance. Self-insured plans are subject to the Federal Employee Retirement Income Security Act of 1974 (ERISA).
The U.S. Department of Labor is the federal government agency responsible for handling matters involving self-insured plans. If you cannot receive satisfaction from dealing directly with the plan sponsor (usually the employer) or with the plan administrator, you may contact the U. S. Department of Labor for guidance. The address is:
U. S. Department of Labor
Frances Perkins Building
200 Constitution Ave., NW
Washington, DC 20210
1-866-487-2365
www.dol.gov
Managed Care Health Insurance Plans
How do I select a managed care health insurance plan (e.g., HMO, PPO)?
Consider what is most important to you in a health plan: cost, availability and location of providers, or freedom to see any doctor. If you like the physician you are currently seeing, check to see if he or she is a provider in the plan that you are considering. If you or a dependent has special medical needs, check that the plan you are considering has adequate medical services and providers for that specialty.
In completing my application for insurance, I noticed that I needed to choose a primary care physician. What does that mean?
Your primary care physician (PCP) is responsible for managing your health care needs. Many managed care plans require their members to receive care from the PCP or obtain a referral from the PCP to receive care from a specialist.
May I use any provider that I choose under the plan?
If you are covered under an HMO, in most cases you will need to receive all services from your PCP or other participating plan providers. Generally, if you are covered under a PPO or POS, you will be able to choose any provider. However, you will be required to pay a larger portion of the bill if you use a non-participating (or non-preferred) provider, and you may be required to have some services preauthorized by the insurance company. Your member handbook or EOC should explain the requirements specific to your plan.
What can I do if I want a different primary care physician (PCP)?
Follow the plan's procedures for changing primary care providers. Consult your member handbook or EOC, or your employer may be able to assist you.
What can I do if my doctor says I need a medical procedure and my managed care health insurance plan says it is not medically necessary?
If you are a participant in a Managed Care Health Insurance Plan (MCHIP), you have the right to request a copy of any utilization-review policy and procedures your plan uses to determine medical necessity for a medical condition. You have the right to file an appeal requesting reconsideration. Consult your doctor and submit any additional important information with your appeal. Your insurance company must have a medical doctor determine if a treatment is not
covered due to medical necessity. You have the right to seek assistance from the Bureau of Insurance, Office of the Managed Care Ombudsman, and your situation may be eligible for further consideration through the Independent External Appeals process.
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