Insurance Coverage

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Insurance Coverage

Postby Bobbie » Thu Jan 26, 2006 2:29 pm

Since insurance is a topic of great concern, see the following for info. Thx. to Diane Stevens and Allison for the info.

Diane Stevens
If you become a self pay patient, the doctor can get all the money they charged you. When they file with their insurance company and they are contracted with them, they are required to take a write off because most insurance companies follow medicare guidlines. So if they doctor charges 60.00 for an office visit, the insurance company usually pays half or less and they make them write the rest off. So if you have no insurance, the doctor can make more money. Now my GI doc is not covered by my insurance and he has elected to write off everything except my copays. Nice of him huh????? He is caring and only wants to see me get better. I trust him. He is in medicine to help people. I have worked with doctors who are the opposite. they are out for the mighty dollar. Talk to your doctor ! Your doctor may only want the best for you. And having all these medical problems and then finding out you owe lots of money can only put alot of un needed stress on you.
Good luck!

Do you have any knowledge about the new insurance provider?
You can learn about their coverage PRIOR to enrolling.

Are you familiar with the HIPPA laws? I suggest going to your state's website about medical insurance issues to learn more.
The new HIPPA laws are highly protective.
For instance, in the state of Pennsylvania, there is no such thing as a pre-existing condition if you enroll in an HMO under group coverage. PERIOD. Insurers are breaking the law if they try it. Insurance companies cannot deny coverage for as many patients as they could in the past.
Many who do employ a pre-existing condition clause must use a "look-back" period of exclusion. Often it's 6 months, so you may be safe.

Get the necessary info first, know your rights and how you're protected by the HIPPA laws before you assume the worst.
Last edited by Bobbie on Thu Jul 31, 2014 12:47 am, edited 3 times in total.
Reason: updating

Posts: 12140
Joined: Sat Aug 06, 2005 8:00 pm

Postby Bobbie » Thu Jan 26, 2006 9:48 pm

Diane Stevens provided this info. Thx., Diane. Diane previously workd as a medical biller so knows her stuff.

We changed insurance coverage at the first of the year. I just received my HIPPA certificate of creditable coverage today which proves that we were insured up untill the new coverage took effect. all the guidlines are in my certificate. And I am posting it for everyone.

The health insurance portability and accountability act, better known as HIPPA, is a federal law that protects health coverage for workers and their families should they change or lose jobs. To help you recieve the full coverage. A certificate, called a certificate of creditable coverage, provides proof and will most likely help you when applying for future health coverage.

Here are three reason why you may need to provide this certification of coverage:
1. To reduce the exclusion period before your new health plan covers a pre-exxisting medical condition
2. To help you get "special enrollment" in another plan
3. To help you recieve certain types of individual health plan coverage, even if you have health problems.

What is creditable coverage? Creditable coverage is prior health plan coverage that is considered by your new health plan to determine the length of time for a pre-exsting condition exclusions. In other words, you're given credit by a new health plan for having coverage under a previous health plan. The amount of credit you recieve depends on how long you were covered under your previous health plans.

Most health coverage is creditable coverage, including group health plan coverage, cobra continuation coverage, coverage under an individual health policy, medicare, medicaid, state children's health insurance program(Schip)coverage through high-risk pools and the peace corps. However, not all forms of creditable coverage are required to provided certificates.

Pre-existing condition exclusions

What is a pre-existing condition? A pre-exsiting condition is a physical or medical illness present before the date coverage began. Under HIPPA, a pre-exsiting condition is limited to medical conditions that you received medical advice, diagnosis, care or treatment for within the six month period before your enrollment date. Pregnancy is not considered a pre-existing condition.

What is an enrollment date? An enrollment date is your first day of coverage, or, if there is a waiting period before coverage takes effect, the first day of your waiting period. Typically, your enrollment date is your first day of work.

What are pre-existing condition exclusions? Some group health plans restrict coverage for medical conditions present before enrollment in a new health plan. These restrictions are called " pre-exisitng condition exclusions" Pre-exisitng condition exclusions apply only to conditions for which medical advice, diagnosis, care or treatment was recommended or recieved within six months before your enrollment date. The maximim time period that a pre-existing condition cannot be covered is 12 months after your enrollment date or 18 months if you are a late enrollee. Pre-existing condition exclusions cannot apply to pregnancy or to a child who is enrolled in a health plan within 30 days after birth, adoption, or placement for adoption. If your plan imposes a pre-exsisitng condition exclusions, the length of time must be reduced by the length of time you had previos health coverage(creditable coverage)

In the amount of creditable coverage you have is equal to or longer than the exclusion period, no exclusion period can be imposed on you. However, if at any time you had a break in coverage(not covered under a health plan for 63 days or more) your new plan may not have to count your coverage before this break.

What is a break in coverage? A break in coverage is a period of 63 or more days during all of which you had no health coverage. (If you get health coverage by midnight on the 63rd day, you did not incur a break in coverage)

It is important not to have a break in coverage, if you do, health plans may not have to consider the health coverage you had before the break.

Your right to special enrollment

What is special enrollment? Under HIPPA. If you lose your group health plan coverage, you may get into another group health plan for which you are eligible(such as a spouse's plan) Even if the plan generally doesn't accept late enrollees. You must request special enrollment within 30 days after your previous coverage ends. You can also request special enrollment if you have new dependents through marriage, birth or adoption.

Your protection against discrimination based on your health

Can a group health plan deny me coverage based on my health? Under HIPPA, a group health plan may not keep you or your dependendts out of the plan based on anything related to health. Also a group health plan may not charge you or your dependents more for coverage, based on health. than the amount charged others in similar situations.

Your right to individual health coverage

What is individual health coverage? under HIPPA, if you are an "eligible individual" you have a right to buy certain individual health policies(or in some states, to buy coverage through a high-risk pool) without pre-exisitng condition exclusions. To be considered an eligible individual, you need to meet the following requirements:
1. you've had health coverage for at least 18 months without a break in coverage of 63 days or more
2. Your most recent coverage was under a group health plan(which can be shown through a HIPPA certification coverage certificate
3. You did not lose your group coverage for not paying the premiums or for committing fraud
4. You are not eligible for cobra continuation coverage, or you have exhausted your cobra benifits(or continuation coverage under a similar state provision)
5. You are not eligible for medicare or medicaid
6. You do not have any other health insurance

If you meet these requirements and want to obtain individual coverage, you should apply as soon as possible to avoid the 63-day break in coverage and subsequently, the loss of your eligible individual status.

Your right to buy individual coverage is the same whether you quit your job, were laid off or fired.

State flexiblity
Hippa certification of coverage is your minimum HIPPA protection under federal law. State laws may require insurers and HMO'S to provide additional protections to individuals. Contact your state insurance department to find out more.

If you have questions about your HIPPA rights contact the U>S> department of labor employee benefits security administration toll- free at 1-866-444-3272 and ask for the free HIPPA publications concerning changes in health care laws.
Dianne Stevens

Posts: 12140
Joined: Sat Aug 06, 2005 8:00 pm

Re: Insurance Coverage

Postby Bobbie » Thu Jul 31, 2014 12:43 am

With Obamacare, many things are changing in the insurance world. Be sure to check on your benefits before seeing a doctor or entering a hospital.

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