Q: My health insurance claim was denied. What are my rights?
A: You can file a grievance by writing or calling your insurance company.
The company will contact you and review your claim. During that process
you may submit additional information and appear in person.
Ultimately, if your company denies your claim after its internal reviews
are finished, you may have the right to an external review. This is a
review of your medical records by an independent review organization assigned
by the Oregon Insurance Division.
For help, contact the Insurance Division's consumer advocates at 503-947-7984 or 1-888-877-4894.
Q: What can I do if my insurance
company denies my doctor's recommended treatment as not medically
necessary?
A: Request a copy of any procedures your insurance company uses to determine
medical necessity. You can file a grievance and follow review and appeal
procedures, including external review if necessary. Ask your doctor for
supporting information to submit with your grievance. Your insurance company
must use a medical professional to determine if a treatment is medically
necessary.
Q: Why is my share of the medical bill higher than expected?
A: This could be for several reasons. For example:
You used out-of-network doctors or hospitals that don't contract
with your insurance company to give you a discounted price. These providers
can bill you for the difference between full charges and the amount paid
by your insurance. In addition to charging more, you may pay a higher
percentage (coinsurance) of the bill if you go out-of-network. For example,
you might pay 20 percent for an in-network provider and 40 percent for
an out-of-network provider.
Your policy doesn't cover some services you received.
Medical complications added to your costs.
Your annual deductible or coinsurance may not have been satisfied
prior to the claim.
Starting July 1, 2009, insurance companies must give you an estimated
cost – using in-network or out-of-network providers – for certain medical
procedures.
Q: Why is it taking so long for
my insurance company to pay the doctor bills?
A: If the insurance company has all the information it needs, it must
pay within 30 days of receiving a claim. However, if more information
is needed, the company has additional time.
Q: Someone from my insurance company
told me a particular surgery was covered, but after the operation, the
company wouldn't help pay. How can this be?
A: Often, advance information is incomplete. Final coverage decisions
are usually based on details in the medical records. Discussions with
an agent or company representative do not change how the policy covers
a procedure. The company may, in fact, say that prior authorization isn't
needed for a procedure. That doesn't mean it will cover the procedure.
The procedure still must meet medical guidelines. Insurance companies
have detailed, procedure-by-procedure guidelines on when coverage is allowed.
You can ask for the guidelines for your particular treatment.
On the other hand, if prior authorization is required and obtained, the
company may be required to cover the care you received.
Other reasons for coverage denials include changes in your coverage or
enrollment status that you don't know about. For example, your employer
may change insurance companies or benefit plans and this happens before
you get a new insurance card. Or, perhaps your insurance ended sooner
than you expected. Maybe the insurance company made a mistake.
For help getting an answer, contact the Insurance Division's consumer
advocates at 1-888-877-4894.
Q: What is a pre-existing condition?
A: A pre-existing condition is a medical condition for which medical
advice, diagnosis, care or treatment was received during the six months
before you enroll in a new health plan. Your insurance company may not
cover these conditions for six to 12 months. However, if you had insurance
before coming to the new plan – with no more than a 63-day gap in coverage
– pre-existing conditions may be covered sooner.
Individual Health Plan Questions
(For those who don't get insurance at work)
Q: I applied for an individual insurance
plan and was turned down for a minor problem. Can the insurance company
do that?
A: Yes. More than 20 percent of people who apply directly to an insurance
company for this type of plan get rejected because of medical conditions.
It could be for a serious medical condition or because of an expensive
prescription drug, or because the company anticipates problems in the
future based on something in your medical history. Companies have their
own height and weight charts and might turn you down based on your weight.
You won't be able to buy a policy if you are pregnant.
However, Oregon has a program for people who are turned down for coverage.
It's called the Oregon Medical Insurance Pool (OMIP). The program is not
based on income. Learn more at: http://www.omip.state.or.us/
Q: I thought companies looked at
five years worth of medical history?
A: When applying for an individual health plan, the application will
request disclosure of all health treatments and conditions over the past
five years. This is to determine whether to insure you at all. Additionally,
the insurance company has the right to request and review medical records
from your physicians, even if they are more than five years old.
Be careful when you fill out the application for health insurance. A
mistake could allow the company to rescind your policy and you would have
to pay any medical bills you accumulated during the time you thought you
had insurance. In other words, it would be the same as though you never
had coverage.
Q: Why did my monthly premiums go
up so much?
A: Moving into a new age bracket increases your premium on top of medical
cost inflation. Medical costs often increase by double-digit numbers every
year due to new medical technologies, costly prescription drugs, an aging
population, and treatment for chronic conditions such as heart disease
and complications of diabetes. Insurance companies set premiums to cover
these costs. In Oregon, 90 cents of every dollar paid in premiums goes
to pay medical claims.
Q: Do my rates increase if I get
sick and make numerous claims?
A: No. Individual rates cannot be based on your health. Individuals of
the same age, and of either sex, pay the same rate regardless of health.
Rates may be increased if all the policies are increased. Your increase
would be the same as others in your age bracket who have the same policy
and same deductible.
Q: Can my policy be cancelled?
A: Your policy cannot be cancelled or non-renewed as long as you pay
your premium on time. However, due to changing conditions, insurance companies
may cancel all policies and replace them with new policies. In such cases
the company must offer you a policy that most closely resembles your old
policy, selected from one of their new available policies. Also, insurance
companies may stop doing business in Oregon if they follow certain rules.
In these rare instances, you would need to apply for new insurance with
a different company. A company may also discontinue or cancel your coverage
for fraud.
Q: What if I can't afford insurance?
A: You or other family members may
qualify for Oregon Health Plan, or Medicaid. Call 1-800-359-9517. Another
state program, the Family Health Insurance Assistance Program, helps pay
the monthly premium for private insurance for qualified, uninsured families.
Call 1-888-564-9669.
You may also want to talk to an insurance agent about ways you can
afford private insurance. For example, some people buy high-deductible
plans to lower monthly premiums or short-term plans if they are between
jobs.
Group coverage questions
(For those who get insurance at work)
Q: Can my employer change our health
insurance company and the benefits during the year?
A: Yes. Employers don't have to offer health insurance. If they do, they
can change companies and benefits at any time. Your employer also has
the right to require that you pay a portion of your health insurance premium.
Q: My employer is dropping coverage.
What do I do?
A: You have a number of choices. They include:
Moving yourself and family members to a spouse's coverage.
Buy a portability policy from the same company that offered insurance
to your employer. The company must send you a notice that offers a portability
policy.
Apply directly to an insurance company for an individual health
plan. This can cover you and family members. However, if someone has a
serious health condition, that person may be turned down.
If you have a health condition and get turned down for individual
insurance, you get coverage though a state program called the Oregon Medical
Insurance Pool.
Q: My employer is self-insured and
says the business doesn't have to follow Oregon law. Is that true?
A: Yes. Self-insured means the employer has not purchased insurance from
an insurance company. Therefore, the plan doesn't have to cover everything
required by Oregon law. Instead, the plan will generally follow federal
laws which are administered by the U.S. Department of Labor.
Follow grievance and appeal procedures outlined in your health plan from
your employer.
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