|
The private
health insurance market continues
to change dramatically in Maine. While health
insurance is available to those who can afford
to buy it, the price for good coverage is out
of reach for many Mainers.
With
the passage of National Health Care Reform, action
has been taken to reverse these alarming trends.
However, as these needed reforms are implemented
in stages between now and 2014, most Mainers are
still faced with the choice between expensive
private insurance that they can use, less expensive
private insurance that doesn't cover what they
need, or being uninsured, if they do not qualify
for public programs.
What you'll
find on this page:
|
... |
|
| |
| |
| |
Health
Insurance Overview
Searching
for health insurance on your own can be confusing. Where
do you look? What do you need to know? What are your rights?
Not only do consumers need to know where to buy health
insurance, it is also important to know basic terms and
rights as you shop.
What
is the purpose of health insurance?
People purchase health insurance so that in time of need
or unexpected sickness, the insurance policy may cover
a portion of the costs of health care. Health insurance
protects against financial loss and/or economic hardship
if you get sick or injured by pooling risks across a broad
number and range of people. Many people view health insurance
as a means to support and protect health by enabling you
to obtain needed care and services, including preventive
care, in a timely and appropriate manner.
Health insurance may cover some or all of the expense
of:
- hospitalization,
- surgery,
- physicians'
fees,
- prescription
drugs and medicines,
- laboratory
tests,
- x-rays
and other diagnostic procedures,
- radiation
therapy,
- maternity
and nursing care,
- eyeglasses,
crutches, prostheses, etc., and/or
- other
major medical expenses incurred in a serious or long-term
illness.
Buying
Insurance Outside of a Workplace
Insurance
policies offered outside of a workplace are called "individual"
or "non-group" plans. These plans are available
to anyone under 65 that can afford them. Both HMO and
Indemnity plans are available in Maine.
Indemnity
plans allow you to choose any health care provider
you wish and will not interfere with medical decisions
made by you and your doctor. However, all indemnity
plans have a deductible-a certain amount that you
are required to pay out-of-pocket before your insurance
will begin paying for services. Deductibles usually
range from $250 to as much as $15,000 per year per
person. Indemnity plans may also require you to pay
a "coinsurance" percentage of any bills
you incur after reaching the deductible amount. Monthly
premiums for indemnity plans for a single person range
from about $150 for a plan with an extremely high
deductible to about $950 for a plan with a low deductible.
Adding family members to the plan will increase your
monthly premiums significantly.
HMO
plans generally cover more services and have much
lower out-of-pocket costs than indemnity plans. However,
HMO plans also limit your choice of doctors and can
refuse to pay for a service if they decide it is unnecessary.
A comprehensive HMO policy that includes prescription
drugs is very expensive. For a single individual,
monthly premiums can range from about $950 to over
$1400. Adding other family members to a plan will
raise the price significantly-often to well over $2,000
a month.
For
more information on prices, coverage, and companies
offering plans in Maine, click
here for a guide from the Maine Bureau
of Insurance.
Buying
Group Health Insurance
Information
on insurance for small businesses, large businesses,
and COBRA
Small
business plans
Small business plans are available to small businesses
with 2 to 50 employees who meet certain requirements.
They tend to be less expensive than "individual"
plans, although prices are quickly rising. However,
small groups can enroll in a new program called DirigoChoice.
You can get more information about Small Group Coverage
from the
Maine Bureau of Insurance at 1-800-300-5000.
Large
group coverage
Large group coverage is available to employers that
have 50 or more workers. It is generally the most
affordable coverage for workers, although costs are
quickly rising. Many companies with large group plans
are "self-insured" which means they assume
the risk and pay claims themselves. You can get more
information from the Maine
Bureau of Insurance at 1-800-300-5000.
COBRA
If you had health insurance through an employer
with more than 20 employees, you may be eligible
for a COBRA plan. This program guarantees continued
insurance coverage after your employment ends. COBRA
lasts at least 18 months, and in some instances
for three years. Your employer is required to notify
you if you are eligible, and you have two months
to decide whether to participate. In COBRA, you
are responsible for the full cost of the insurance,
which could cost anywhere from a few hundred dollars
to over $1,000 a month, depending on the type of
coverage and number of family members covered. You
can get more information from the Maine
Bureau of Insurance at 1-800-300-5000.
Understanding
the Lingo
How
can people choose a health insurance plan? To make an
informed decision, it is necessary to first understand
the language of insurers. Below are definitions of commonly
used terms and phrases.
The
Annual and Lifetime Maximum Benefit Amounts
(or Lifetime Cap) are the maximum dollar amounts
the plan must pay for all health care services provided
to an insured per year (annual) or in his or her lifetime
(lifetime cap). If these amounts are exceeded, the insured
is responsible for the full cost of services beyond
the cap. A combination of Maine and federal law prohibits
“total” annual and lifetime limits on most
plans. However, certain limits on specific services
can be applied in many cases.
The
Certificate of Coverage provides detailed contractual
information about the benefits covered by the plan.
It is important to fully understand this information
when evaluating whether the policy covers the health
care services you need.
Claims Procedures: This is typically a couple
of pages describing the claim filing procedure. The
important section here is the part that provides information
about how to appeal denials of coverage.
COBRA refers to the Consolidated Omnibus
Reconciliation Act which allows employees
in certain circumstances to continue, for a limited
period of time, health insurance coverage through their
employer after they are no longer employed by that employer.
It does not apply to all employers.
A Copayment (or co-pay) is a flat fee paid directly
to the provider when you receive a medical service (for
example, $10 for every visit to the doctor).
Coinsurance is the amount or percentage that
you are required to pay for medical care after you have
met your deductible. Expression of the co-insurance
rate is usually a percentage, for example, if the insurance
company pays 80% of the claim, you pay 20%.
Coordination of Benefits is a system used to
eliminate duplication of benefits when a person has
coverage under more than one health insurance plan.
Covered Benefits: Often separate from the schedule
of benefits, this is a listing of what is covered. In
some plans, it will be a long list; others will give
a short list of a broad range of benefits covered. This
section will also give more detail about what and how
things are covered.
A Deductible is the amount of money you must
spend each year on your medical care expenses before
your insurance policy starts paying. Some services under
some policies may not be subject to the deductible (for
example, preventive services). This means the insurance
will cover these services immediately even if you have
not met your yearly deductible.
Eligibility: This is an important section in
the Certificate of Coverage as it tells when coverage
actually begins.
Exclusions
and Limitations: This lists the services and procedures
that the plan will not cover, such as experimental treatment
or cosmetic surgery. It also lists items that have special
limits on coverage, such as mental health care, convalescent
home care, or treatment for conditions that existed
when coverage started, known as pre-existing conditions.
An Explanation of Benefits is a document you
get from your insurance company after you receive health
care and a claim is submitted to them for payment. The
document tells you what claims they paid or did not
pay, and why. If they did not pay a claim and you think
they should have, you can appeal that denial of payment.
The
Insured is the person covered by the health insurance
policy.
Maximum
Out-of-Pocket is the most money you will be required
to pay each year for deductibles and coinsurance. It
is a stated dollar amount set by the insurance company,
in addition to regular premiums. Once the maximum out-of-pocket
amount is paid, the insurance company will pay the full
amount for all covered services (as long as you continue
to pay the premium).
In-Network
and Out-of-Network Refers to the provider. In-network
providers contract with the health insurance company
to provide services to plan members for specific pre-negotiated
rates. Out-of-network providers have not contracted
with the health insurance plan. You will pay probably
pay less if you visit a provider in network than out-of-network.
A
Pre-existing Condition is a health problem that
existed before the date the insurance became effective.
Sometimes pre-existing conditions can be excluded from
coverage in certain circumstances.
The
Premium is the amount the insured and/or their
employer pay in exchange for insurance coverage.
Schedule
of Benefits: This is often at the front of the plan.
It is the part that details what the insurance company
pays and what the employer and employee pay for different
categories of service. It lists such things as deductible,
co-insurance, and co-pays expected at each doctor’s
visit.
Understanding
Your Rights: Consumer Protections
Every
state has a department of insurance. In Maine, this
department is called the Bureau of Insurance. This Bureau
enforces laws and regulations regarding insurance and
governs most insurance companies. The Bureau of Insurance
is a resource for consumers, offering information on
what companies legally sell policies in Maine, what
scams consumers must watch out for, investigating consumer
complaints against companies and regulating the companies
themselves. Following are areas that affect your coverage
and its cost, which the Bureau regulates.
Continuity
of Coverage (Restrictions on pre-existing condition
exclusion periods)
- Prevents insurers from denying coverage to people
who have lost coverage (e.g., due to job loss or change
of jobs) and have medical conditions.
- Employees have 90 days within which to obtain new
coverage after previous coverage ends.
- This period may last up to 180 days (in Maine) if
the person is unemployed and receives unemployment
compensation prior to becoming employed and seeking
new medical coverage.
- If you have been without coverage for more than
90 days, an insurance carrier can deny coverage for
a "prior" medical condition but for no more
than 1 year.
Fair Pricing
- Limits the difference in premium costs that an insurance
carrier charges for a certain policy (offered to individuals
and small employers) based on various factors such
as: age, geographic location, and industry.
- No rate variation allowed based on gender, health
status or claims experience.
- Unlimited rate variation allowed for: family size,
wellness program participation, smoking status, and
group size (for employer coverage).
- Some of these provisions may change as new health
care reform laws are implemented.
- Sometimes called Community Rating.
Access to Coverage
- Sometimes called Guaranteed Issue.
- If a carrier offers coverage to one person (in the
non-group or small group market), it must offer coverage
to all paying customers.
- Guaranteed renewal is similar, but applies to policies
at renewal time.
- If you have not missed payment, you cannot be denied
renewal of coverage because you or someone in your
family has developed an illness.
Mandated
Benefits
- Services that insurers are required to cover or
offer to cover in their health care policies, such
as:
o Equipment and supplies for diabetes treatment
o Mammography and pap test screening
o Prostate cancer screening
o Coverage for prosthetic devices
o A full list can be found on the Maine Bureau of
Insurance website here: http://www.maine.gov/pfr/insurance/consumer/mandated_benefits.htm
Understanding
Your Rights: Claims and Appeals
Under
the national health care reform law, known as the Affordable
Care Act, there are new rights for consumers related
to appeals. These new rights improve Maine’s laws
that protect you and give you certain rights when it
comes to dealing with your insurance company, including
the right to file appeals and complaints.
The Maine Health Insurance Consumer Assistance Program
can help you navigate the appeal and complaint process.
You can reach the Program by calling 1-800-965-7476.
What’s
a denial?
A “denial” means that the insurance company
has decided not to pay for the procedure that your doctor
has recommended. There are two kinds of denials. If
this is a procedure you need to have in the future,
the insurer may be denying a request for “prior”
or “pre-authorization.” If the claim is for
a procedure you’ve already had, then the denial
may be for “reimbursement.”
Why
do insurance companies deny claims?
The company may say the procedure is not “medically
necessary” and deny the claim. In other cases,
the procedure is not covered by the plan or the person
may not be eligible for the plan or certain benefits.
What do I do if my claim is denied?
If your health insurance company denies payment for
a service, here are some options you have depending
on the circumstances and the type of insurance plan
you have.
Step
One: Internal Appeals
Most health plans have a process that lets you appeal
the decision within the plan through an “internal
appeal.” You can file an internal appeal with the
company within 180 days. The denial letter (known as
an “explanation of benefits”) should have
information about how to file an appeal included in
it. In most cases, you can call or write and describe
the situation. You may wish to get a copy of the plan’s
“certificate of coverage” if you don’t
have it already. This is the legal document that describes
the policy and what benefits are covered. In an appeal,
you should be as specific as possible in describing
the details of your condition and why you believe the
insurance company was wrong to deny payment.
The company has 30 calendar days to respond to an appeal
for a “pre-authorization” request and 60 calendar
days to respond to a “reimbursement” request.
In an urgent care situation, the company has 72 hours
or less, depending on the case. Depending on the type
of policy, you may have one or two opportunities to
file an internal appeal (referred to as level 1 and
level 2 internal appeals).
Step
Two: External Appeals
If the insurance company still won't pay the bill or
cover the procedure, you can file an external appeal
with an independent review board. You do this through
the Maine Bureau of Insurance. You have 12 months to
apply for an external review after the level 2 internal
appeal is denied. Contact the Bureau directly (1-800-300-5000)
to request an external review at no cost to you. They
will send you a packet and contact sheet to fill out
and return.
Note: Depending on the type of plan you have, you may
not have access to this type of appeal.
The
Bureau will decide if your case relates to medical necessity,
pre-existing conditions, experimental/investigational
services, or medical diagnosis, care, or treatment only.
If it does, the Bureau will decide that your case qualifies
for external review.
Then the Bureau will assign your case to an External
Review Board which will gather evidence and conduct
a hearing. The Board has 30 days to make its decision
unless the patient’s medical condition requires
urgent care and an expedited or rushed appeal. It is
important to see the appeals process through; one study
found that consumers won their external appeal against
the insurance company 45% of the time.
Note: Government programs such as Tricare (military),
Medicare, and MaineCare (Maine’s Medicaid program)
have their own appeal processes that are similar to
this and that are usually detailed in your policy papers.
You can find out more by contacting the program directly.
Filing
a Complaint:
If, at any time, you have concerns about an insurance
company, you may file a complaint with the Maine Bureau
of Insurance. This is a separate process from the appeals
processes outlined above. It is best to do both at the
same time: file internal appeals directly with the insurance
company AND file a complaint with the Bureau of Insurance.
The Bureau assigns an investigator to the complaint
and the company has 14 days to respond. This complaint
process does NOT replace
the
appeals process; it is merely another tool at your disposal.
More Consumer Appeal Rights Coming Soon!
Starting in January 2012, insurers will be required
to provide notice to consumers about the diagnosis and
treatment code, date of service, denial code, and the
reason they denied a claim. The company will also have
to notify you of your appeal rights.
Questions? Need Help?
If you have questions or need assistance with any of
these options please call the Maine Health Insurance
Consumer Assistance Program at 1-800-965-7476 (toll-free).
They can help guide you through the process, file an
appeal or complaint, and may be able to represent you
at a hearing. The Maine Health Insurance Consumer
Assistance Program is a partnership of the Maine Office
of the Attorney General and Consumers for Affordable
Health Care. www.mainecahc.org/mhicap.htm
Understanding
Your Options
When
considering health care coverage, the process can seem
overwhelming. Each insurance company offers a wide variety
of plans, each with different costs and coverage. Sometimes
the differences among policies are straightforward (for
instance, a $500 deductible versus a $1,000 deductible)
and may be easy to quantify. Other differences are more
difficult to quantify (for example, limits on number of
visits for different services). What makes the process
even more challenging is that it is virtually impossible
to find an “apples-to-apples” comparison
between plans offered by different insurance companies.
It can even be difficult to compare policies offered by
the same company.
How much does health insurance cost?
For most people, the first issue to consider is the cost
– how much can you afford to spend on health insurance?
The most obvious cost is the premium amount. This will
be one of the first pieces of information provided by
the insurance company or insurance broker. However, it
is important to note that the premium is not the only
component that makes up the overall cost of the product.
The product will likely contain one or more of the following
expenses that relate to the total “out-of-pocket”
cost of the product
- deductible,
- coinsurance,
- co-payments,
- maximum out-of-pocket, and/or lifetime maximum.
How
do I evaluate the quality of coverage?
While price is obviously a critical factor in the decision
to purchase health insurance, it should not be the only
factor considered. Quality of health care and health
insurance coverage is also an important factor.
Not just "How much does the option cost compared
to other plans?¨ but also, "What benefits and
services are covered compared to other plans?¨
There are, of course, some basic questions to consider:
- How much do I have to pay out of pocket before services
are covered?
- Are there restrictions on coverage for certain services?
- Is the appropriate care available when it is needed?
- Does the care conform to accepted medical standards?
- Are preventive needs addressed, as well as acute
and chronic illnesses?
- Does
the plan cover the services that I know I will need
(for example, treatment for a pre-existing condition
or a specific prescription)?
A
careful review of the Summary of Benefits is
one of the first steps one should take in evaluating
coverage in a particular plan. However, it is important
to note that it is only a summary and does not include
a lot of details about specific types of coverage or
limitations on coverage. In addition, the Summary of
Benefits is not actual contract language. One may need
to closely examine the actual policy or contract (known
as the Certificate of Coverage) to truly understand
the health plan’s coverage and limitations. Many
of these contracts are posted online* or you can request
one from the company. In addition, discussing the details
with a health insurance broker, customer service representative,
Bureau of Insurance staff person, or a Consumer Assistance
Program will help assess the value of the policy.
*http://www.state.me.us/pfr/insurance/consumer/brochures.htm#health
High-Deductible/Catastrophic Plans
- Limited benefits and/or high deductibles in return
for lower premium costs (note: not a 1:1 return)
- Deductibles can be up to $5,000 - $15,000 or more
annually
- Catastrophic coverage by definition covers limited
benefits
- Some high-deductible plans also have limited benefit
coverage
Health
Savings Accounts (HSAs)
- Tax-advantaged savings accounts associated with
high-deductible health insurance plans
- deductible must be at least $1,200 for individual
coverage and $2,400 for family coverage in 2011
- out-of-pocket amounts, including deductibles and
co-pays, cannot exceed $5,950 for individuals and
$11,900 for family coverage in 2011
- HSA statutory contribution amount can't exceed $3,050
for an individual, and $6,150 for a family in 2011
- these numbers change periodically due to federal
IRS regulations
- HSAs are an expansion on medical savings accounts,
which were much more limited in who was eligible to
participate
Using this worksheet
to compare each plan will allow you to be sure you get
what you need for the best overall price, including
all costs, not just the monthly premium.
Online
Health Care Guide