Insurance Existing

Insurance Existing Condition

2015-08-23T21:51:00.000-07:00

Insurance existing condition is a clause in the insurance policy that states a members claim will not be covered or it can be denied for any medical illness, diagnoses and treatment before the new insurance effective date. The pre-existing condition is any medical condition that was diagnosed and treated within a specific time before the new insurance effective date or new insurance was obtained. An insurance company can cancel or deny a claim if the policy holder failed to inform them of a pre-existing condition.

The language on the pre-existing clause varies from policy to policy. It use to be that if an employee left one employer for another they would need to wait a certain period before they can be covered and/or if they had a medical condition that was diagnosed and treated before the new insurance, they would probably not have been covered. A careful review of the denied claim can determine if there was an error in the coding of the claim by the medical office, or if the condition was indeed pre-existing. The Health Insurance Portability Accountability Act 1996, (HIPAA) was designed to allow an employee to move from one employer to the other without risk of not being covered.

HIPAA also protects individuals who change from group plans to an individual health plan. Depending on some states, some group coverage may make the employee wait 12 months for pre-existing condition after enrollment and 18 months if the enrollment period was missed. If the new employer provided insurance does not have a preexisting condition clause, it can still require a “waiting period” of up to 6 months before the employee insurance coverage is effective. You can not be denied health insurance coverage if you had continuous insurance coverage with out break, under the Consolidated Omnibus Budget Reconciliation Act COBRA continuation coverage. There are insurance companies out there that provide coverage for individuals with serious health problems, as well as individual state funded insurance.

Insurance existing medical conditions are not always easy to obtain but they are out there. Some pre-existing insurance will have you wait of twelve month coverage before your pre-existing condition can be covered.

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Children's Health Insurance Program Reauthorization Act of 2009 (CHIPRA)

2009-11-15T19:21:00.000-08:00

On February 4, 2009, the President signed into law the Children’s Health Insurance Program Reauthorization Act of 2009 (CHIPRA).
CHIPRA, finances the Children's Health Insurance Program Reauthorization Act of 2009 (CHIPRA or Public Law 111-3). The law provides provisions that affect both the Children’s Health Insurance Program (CHIP).
CHIPRA, reauthorized the Children's Health Insurance Program (CHIP)through 2013. CHIPRA will strengthen each states existing programs and provide coverage to additional low income, un-insured children and pregnant women. It will also provide States the option to provide Medicaid /CHIP to qualified legal alien children and pregnant women that reside legally in the Unite States.

Women’s Health and Cancer Rights Act of 1998 (WHCRA)

2009-04-04T14:21:00.000-07:00

Women’s Health and Cancer Rights Act of 1998 (WHCRA) is a Federal Law that applies to women who have had a mastectomy and require or decide to have breast reconstruction due to a mastectomy. Under WHCRA, if your health insurance covers mastectomies, the insurance must provide for certain reconstructive surgeries as they are subject to WHCRA guidelines.

This law applies to the types of coverage:

Group health plans.
Self-funded group health plans.
Individual health insurance policies.

( For those covered under Medicare and Medicaid they must check with their specific agency to verify and discuss their benefits.)

The WHCRA requires under the law that health insurance groups including HMO’s to inform patients about the WHCRA Act.

Patients must be notified;

An initial one-time notice requirement after the 1998 enactment of WHCRA.
Upon enrollment into a group plan or individual (non-employment based) policy; and
Annual notification to group and individual participants.

Coverage must be provided if WHCRA pertains to you and are receiving benefits due to a mastectomy and decide to have breast reconstruction.

The coverage must be provided for:

All stages reconstruction on the breast the mastectomy was performed.
Surgery and reconstruction on the other breast for symmetrical appearance.
Prostheses and any physical complications of all stages of the mastectomy.

Newborns' and Mothers' Health Protection Act of 1996 (NMHPA)

2009-03-21T18:22:00.000-07:00

Newborns' and Mothers' Health Protection Act of 1996, known as the Newborns’ Act, (NMHPA) required by Federal Law, that health plans may not restrict benefits for a mother or newborn child for any length of hospital stay. The law requires the health plans that provide maternity health coverage to pay up to 48 hour hospital stay, following vaginal birth and 96 hour for Cesarean Section delivery. The Newborns’ Act, (NMHPA) was effective for health plans after January 1, 1998. Due to clarifications issues, regulation changes were published by the Departments of Treasury and Human Services and the Department of Labor, and the changes were effective for health plans after January 1, 1999.

In general, group health plans and health insurance issuers that are subject to NMHPA may NOT restrict benefits for a hospital stay in connection with childbirth to less than 48 hours following a vaginal delivery or 96 hours following a delivery by Cesarean section. The time of coverage starts at the time of the delivery, but if the mother delivers outside the hospital and then later admitted to the hospital the time of coverage then starts at the time of admission.

The attending physician may discharge the mother or new born earlier after consulting with the mother.

Federal Law applies unless State Law requires a longer stay. Check with the insurance to see if a longer stay rule applies. The law prohibits any incentives or encouragements to the mother, whether good or bad that would encourage less than the protection under the Newborns’ Act (NMHPA) .

Indemnity Policy

2009-03-15T16:40:00.000-07:00

Indemnity Policy or indemnity plan is an insurance agreement to compensate a party for damages or disabilities. This is a type of traditional insurance offered where other insurance products are not available. For example some states do not have disability insurance for injured workers, an individual or employee can purchase an indemnity policy to cover him in the case of an injury or illness if he is not able to work. The policyholder can submit his claim to the insurance and then be reimbursed directly. The indemnity plan pays a fixed dollar amount to the policyholder for fees incurred for medical office visits, PPO, and or hospitalization. The insurance pays the insured or the hospital a fixed amount for every day the insured is hospitalized. Depending on the insurance policy it may also cover for nursing care or nursing facilities, etc. The fees are based on what is known as Usual and customary and reasonable fees. This type of policy is crucial for families because it protects from major losses which can be devastating to their finances and livelihood, if one of the breadwinners should become ill or injured. It is also important to review the policy yearly. Due to the rising cost of medical care the individual wants to make sure that the indemnity policy compensation meets the currents costs.

Point of Service - POS

2009-02-18T17:31:00.000-08:00

Point of Service (POS) plan is similar to an HMO (Health Maintenance Organization) plan. The POS offers coverage within network but also offers coverage outside the network without prior authorization or referrals (pay for the services out of pocket, then send in claim for reimbursement) versus an HMO, where you must seek medical care within the network. In HMO if you are treated outside the network you may have to pay the charges. There are exceptions for emergencies.

In both Point of Service (POS) and HMO a PCP (Primary Care Physician) must be selected at the time of enrollment. The PCP will manage the medical care for you and your family. The PCP will manage and coordinate all authorizations and referrals for procedures, diagnostic tests, and specialists. Like the HMO when you seek care within the network you’ll provide your ID card and only pay your co-payment. But, unlike the HMO, the Point of Service POS, you can seek care outside the network without a referral.

Coordination of Benefits - COB and Birthday Rule

2009-02-17T21:43:00.000-08:00

Coordination of Benefits - COB and birthday rule, is a method used by carriers to avoid duplication of payments on insurance claims when a patient is covered by more than one policy.
If you or your covered dependent carry other health insurance coverage benefits under another plan, (e.g. you are under a spouses insurance plan, or double coverage) the insurance carrier will determine which insurance plan will pay first or be the primary insurance, this is term coordination of benefits- COB.

The primary insurance will pay first. Meaning if the patient has insurance through his employer, his insurance will pay primary. Once the payment and the explanation (EOB) have been received by the office, then the balance of the claim is submitted to the secondary insurance.

For covered dependents, children, the coordination of benefits COB and the birthday rule have a few variables. The primary insurance usually pays first. But it both parents have equal coverage, the “Birthday Rule” then applies. The rules states:
The parent whose birthday occurs first in the year, his/her insurance will pay first, then the other parent will pay second.
If both parents have the same birth dates, the insurance plan that has been in effect the longest, pays first or primary.
If the parents are divorced the parent with the custody, his/her insurance is primary.
If there is a court order dictating which parent is responsible for guardianship and medical care, the court order takes precedence (priority).

Pre-Certification for Medical Necessity

2009-01-24T18:42:00.000-08:00

Most insurance carriers require certain procedures to be pre-authorized or pre-certified. Most medical procedures need an authorization from the insurance company to authorize the procedures before they can be performed, or the patient will incur the cost of the procedure. It’s imperative that the patient check with his insurance carrier for his coverage specifics to avoid denial of the
claim or procedure.

Pre-certification is a clerical administration process submitted by the physicians office or surgical center, listing the treatment plan to the insurance company or third party before any treatment is performed for authorization.
The insurance company or third party will review for medical necessity of the prescribed treatment plan. This process does not guarantee eligibility for treatment or payments.

What is an HMO health and HMO providers

2008-12-02T21:01:00.000-08:00

What is an HMO, HMO health and HMO providers? An HMO health maintenance organization. An HMO is a comprehensive group of network providers or group of providers specialists that provide quality and cost effective health care services to patients within that group. You'll be assign an identification card and on that card will list your responsibility for co-payment, the name of your primary care physician and your group number. There are no claims to be filed and there is no deductible to meet. By seeing Physicians within that group the patient pays a minimal fee such as a co-payment and usually no fees for labs x-rays and no deductibles.

Managed care organizations have been around since the 1970s, it was developed on the concept of promoting and providing counseling on good health, educating patients on such matters as nutrition, exercise and ways to manage their health for e.g. hypertension, weight control, smoking cessation, drug rehab, and encouragement of annual physical exams and PAP test, breast exams and the likes and thus maintaining the cost of healthcare down.

Employers and insurance companies negotiated with each other and were able to provide the employee with low cost benefits. This also meant that employers can provide better benefits to their employees at affordable prices. These benefits are for health coverage only, an HMO does not cover Workers’ Compensation, or injury on the job. These injuries are covered under employer compensation plan for the injured worker. Usually the employer pays a portion of the cost and the employee pays the remaining which is known as a premium. As later explained the employee will be responsible besides paying his monthly premium, he will be responsible for a co-payment at the time of visit. This is usually minimal fee. An HMO is good insurance plan for families, and young individuals.

At enrollment you the client selects PCP (primary care physician). Your primary care physician manages all your health care needs. Your Health Care Physician will manage all your authorizations to specialists such as internal medicine, pediatrician, gynecologists, labs and all diagnostic needs. The patient is to see the doctors within that network only, if the patient sees a physician outside the network he will be responsible for the charges as you will not be covered.
To avoid claim denials read about pre-certification for medical necessity

Physicians enrolled and credentialed with an HMO, once approved are placed on our roster and patients would be able to select by location the physician of their choice. Physicians will get paid once they see the patients and they send in the claims to the HMO, Physicians can match what patient they've seen against the roster that is sent to them by the HMO. Physicians are paid also a monthly fixed capitation fee regardless of provided services for seeing HMO patients.

Consolidated Omnibus Budget Reconciliation Act (COBRA) 1986

2008-08-23T22:06:00.000-07:00

Consolidated Omnibus Budget Reconciliation Act (COBRA) 1986, is an insurance for those employees who are covered under an employer sponsored insurance plan with more than 20 employees. COBRA provides the same health insurance as the employee had while employed. COBRA is provided for those employees that leave an employer at will or by termination. You may only be eligible for COBRA if you are currently or were employed within 60 days of leaving the workplace. You are only eligible for COBRA if current employed, and no longer have health benefits, or unemployed.

The COBRA Act gives them the right to continue their health insurance coverage for up to 18 months. The employee will pay full premium. Once terminated from the employment the human resource department will send to the employee paperwork to begin the process for coverage under the COBRA plan. The employer will no longer pay for the coverage, the full cost will be paid by the employee. This can be very costly for some. The cost can be up to 102%.

The COBRA plan benefits are same as the original health insurance coverage that the employee had previously before his termination of employment.

When to Consider a COBRA Alternative

Health Insurance Portability Accountability Act (HIPAA)

2008-08-23T22:04:00.000-07:00

In 1996, Congress passed the HIPAA Act that contain provisions for persons covered in an employer sponsored insurance plan, to move from one employer to another without regard to their health conditions if they change their employment.

The Act prohibits screening or testing information to deny insurance coverage. HIPAA also contains tax incentives for long term care insurance.

Due to the electronic submission of claims HIPAA requires new standards for claims filing, electronic submission of claims, standards for attachments and standardization of the diagnostic and procedural coding as well protection for the transmission of electronic data. This is also known as the Privacy Act. HIPAA protects and has sets standards for the confidentiality of patient medical records, Patient Health Information (PHI) and security.

Workers’ Compensation Insurance (Work Comp)

2008-08-23T22:01:00.000-07:00

Workers’ Compensation Insurance - Before Workers’ Comp. came about there was no insurance coverage to protect an injured worker. An injured worker is anyone who is employed and is injured on the job. It will also cover an employee if he was hurt during his lunch hour, while running an errand for the company. In the past employers were responsible for the cost of all treatments and wage compensation. This caused many employers to reluctantly not report the injury.

The worker also had to prove that the injury was caused at work by an employers fault. Due to the amount of injured workers per year and industrial accidents legislation had to make provisions for the injured worker. It relieved the employer from being liable except if there was negligence, and it also compensated the employee for wage loss due to the injury, and medical coverage. This coverage also includes rehabilitation to get the employee back to work.

There are two ordinances for Workers’ Compensation; Federal employees apply to the those working for the government. State employees compensation are for state and private businesses employers and employees, the laws vary from state to state.

When a worker is injured on the job, he must report the incident to his supervisor and complete an incident report, the employer will then send the employee to a clinic or hospital to be treated. Once at the inpatient or outpatient facility the injured worker will then need to complete another form as to whether this was the first place of treating, all records are crucial for the appointment. The employer and clinic will submit the reports to the workers’ compensation office and then an insurance claim adjuster would be assigned to the case for review and approval, of medical care and compensation. Each time the employee is seen by the assigned physician or physical therapist a report will be sent to the Workers’ compensation adjuster, as to monitor the care. All states vary on the time allowed to report and injury.

The worker may or may not be able to returned to work as light duty, light duty restricted, partial disability, or permanent disability. Insurance existing Work Comp

Pre-Existing Condition

2008-08-23T22:00:00.000-07:00

Pre-Existing Condition is any condition diagnosed and treated before the new insurance takes effect. In the past a pre-existing condition was a range of illnesses such as chronic cough, high blood pressure, and even pregnancy, insurance companies would not enroll an employee because of the illness. The employee would have been considered a risk. The HIPAA Act, provides protection to workers that loose their jobs due to voluntary or involuntary, when obtaining new insurance benefits in their new employment.

There are exclusions to insurance health policies, some companies have more than others. An exclusion is an illness, or procedure, excluded, not covered by the insurance plan. For example certain illnesses, (cancer), injury, self inflicted wounds, military injury and suicide. These would not be covered in the insurance health plan. Personal injury, and car injury would be covered under auto insurance policy, if there is no coverage then the health insurance would take over. If there is an attorneys lien, and/or compensation is expected or received through a law suit, the health insurance company would need to be reimbursed the monies paid out for the coverage provided. If the injury happened at work then the injury would be covered under Workers’ Compensation Insurance, (Work Comp ) each state varies. Insurance existing...pre-existing condition
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Pre-Existing Clause

2008-08-23T21:58:00.000-07:00

Pre-Existing Clause is a short sentence or statement, after a description or subject has been given. A separate section of writing (clause) is to alert the reader (e.g. XYZ Health Insurance covers all major illness. (clause: insurance will not provide coverage for pre-existing condition such as chronic throat illness, cancer, gastric bi-pass surgery). Learn more on insurance existing condition.