Health Insurance FAQ

How do I get health insurance?
Contact health insurance agents that live in your area. They can provide quotes with a variety of insurance companies.

Can my health insurance policy be nonrenewed?
"Yes, if your policy does not contain a clause called guaranteed renewability. Nonrewal means that your insurance company has decided against renewing your insurance policy."

Are there differences between health insurance policies?
Yes. Policies vary widely in coverages offered and premium prices.

What is a deductible and coinsurance?
A deductible is the amount of money that you must pay a health care provider before your insurance policy will pay. Coinsurance in the percentage of money that you pay after your deductible is met. Most companies have coinsurance clauses that state the insurance company pays 80% while you pay 20%.

What is an explanation of benefits?
"An explanation of benefits (EOB) provides claim information detailing dates of service, the name of the provider, the type of service (like an office visit), and the amount paid to the provider."

Can I cancel my policy and get a refund?
Cancellation and refund rules vary by state and insurance company. Check with your insurance agent or call the insurance company directly for specific rules about your policy.

What is an office visit co-payment?
This is the amount your insurance company requires you to pay when you visit your doctor for an office call.

What is a Preferred Provider Organization?
A preferred provider organization (PPO) contracts with providers for set fee amounts to save money on expenses for the insurance company.

What does a network provider mean?
Your insurance company usually provides a list of health care providers like doctors or hospitals with whom they have fee contracts. You must choose a provider from the list to take advantage of the lower prices offered by the PPO plan.

What happens if I visit a doctor who is not a member of my plan network?
You will have to pay the difference between the amount your insurance company would pay a network provider and the actual amount charged by your new provider.

What if I can’t afford health insurance?
Medicaid is available to qualified low-income residents of every state. Some states offer other programs for people who do not qualify for Medicaid. Check with your state insurance department for more information.

My group plan through my employer is self insured. What does that mean?
"Your employer has established a health benefit plan that allows the company itself to pay for medical expenses for employees. Most of the time, your company will contract with a separate company to process claims called a third party administrator (TPA). Federal law exempts self-insured plans from state regulation. This means that state insurance laws do not apply to your group plan. Check with your group administrator for more information."

Can I take my group health insurance with me when I change jobs?
"You will not actually take the exact plan you have now. You will be given credit for the time you were covered under your current policy. If your new policy has a waiting period before covering preexisting conditions, they are required by the Federal Health Insurance Portability and Accountability Act of 1996 (HIPAA)to credit the time you were covered under another group plan against any preexisting waiting periods."

What does preexisting condition mean?
"The exact definition varies according to each state’s laws. Generally, a preexisting condition is any diagnosis or treatment that you received prior to the policy inception date of your new policy. Insurance companies may deny coverage for some of these conditions for a specified amount of time."

Are there any preexisting conditions that cannot be excluded under group health plans?
"Yes. If you are pregnant when you begin your new group health plan, they are required to cover your pregnancy related expenses."

Can I keep my current group insurance when I quit my job?
"If you leave your current job and for whatever reason are unable to continue insurance right away, you can continue your insurance up to 18 months. You will have to pay both your portion of the premium and your former employer’s portion, which can be very expensive."

I lost my group insurance when my employer went out of business. Can I continue my health insurance?
No. You can convert your coverage to an individual policy that is reasonably similar to your current policy.

What does a primary care provider mean?
"A primary care provider is a doctor who manages all of your health care needs. If you require a specialist, your primary care physician will give you a referral to a qualified doctor."

What if I want to change providers?
"You will need to contact your plan administrator and follow their guidelines."""

What happens if I need emergency care?
Most policies allow you to go to any provider in an emergency. Contact your insurance company for specific details on their rules.

Does the specialist I will visit for my referral have to be a plan provider?
"Yes, if there is one available."

Do I need to contact my insurance company if my primary physician referred me to an out of network doctor?
Yes. Your insurance company must issue a preauthorization before your visit.

Is my child covered while away from home attending college?
"Yes, for emergency or urgent care. Follow up for routine treatment must be with plan providers located in your child’s city."

Can I choose any doctor I desire?
Your primary doctor must provide all routine care if you are a member of an HMO. Preferred provider plans allow you to choose your doctor from a list of providers.

Will I have to pay all expenses if I do not follow preauthorization requirements?
"Yes. You will have to pay a larger amount of the claim. Sometimes, the claim may be completely denied."

What does formulary mean?
Formulary drugs are an approved list of drugs the company for which the insurance company is willing to pay. They are often called generic drugs. Plans prefer generic drugs because they cost less money than name-brand drugs.

What if I have a problem with my insurance company?
"Contact the customer service department for your insurance company. If they are unable to resolve your complaint, you have the option of writing a grievance. Your policy will give instructions on filing procedures."

Can I continue to see my doctor if he is no longer a member of my plan?
"That depends on the type of plan. Most insurance plans have different co-payment amounts and fee scales for out of network providers. An HMO will allow you to see the same doctor for the remainder of the year. If you are in the 2nd or 3rd trimester of pregnancy, you may continue care through the postpartum period. Specialists can be seen for 90 days or to the end of the current treatment."

How do I know if my plan is an HMO or a PPO?
"Your enrollment papers should describe the type of plan you have. If you are unable to locate the information, contact your plan administrator."

"If I leave my job, when does my group insurance expire?"
"The exact amount of time can vary. Usually, you will have coverage through the last day you worked or until the last day of the month you quit."

Can the group plan offered at my new job deny me a policy because of my health?
No group plan can deny coverage based on health.

What is a waiting period?
A waiting period is the time a new employer may require before allowing you to be included in group health care insurance plan.

Will my group plan exclude preexisting conditions because of the waiting period?
Federal law requires that any preexisiting exclusion period begin on the same day the employer’s waiting period does. Preexisting exclusion periods vary among plans. Check with your plan administrator for specific details.

My primary provider will not refer me to a specialist. What can I do?
"Follow your plan grievance procedures. You may have to pay for care yourself until the issue is resolved, if you choose to visit a specialist without plan permission."

My plan is being eliminated. How do I obtain insurance when I have a serious health condition?
That depends on your state. Some states have insurance risk pools established to offer insurance to people in your situation. Other states require insurance companies to offer you an insurance policy in spite of your condition. Check with your state insurance department for details.

How do I obtain insurance through a state risk pool?
Contact your state insurance department for procedures.

I live in a state that does not have a risk pool. How do I get insurance?
Contact your state insurance department for specific procedures. Your state may require an insurance company to provide you with insurance.

Can a network doctor charge me more for services than my plan pays?
Network providers sign a contract that contains fee provisions. They are not allowed to charge you more than your plan contracted to pay them.

The hospital wants all of my bill paid right away. What can I do?
Contact your insurance company immediately.

I believe my doctor made a mistake in my treatment. What can I do?
Contact your state department of insurance for complaint procedures.

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