Office of Insurance and Safety Fire CommissionerRalph T. Hudgens
Commissioner
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Health Insurance Frequently Asked Questions



Health Insurance is a general term for insurance against loss by sickness or bodily injury. It typically includes coverage for expenses such as doctor visits and hospital stays, and can cover normal and preventive care such as check-ups, prenatal and baby care.

Claims not being paid ?

Delay and denial of claims are the most common inquiries received by the Consumer Services Division. Claim delays and denials occur for numerous reasons and usually stem from contract limitations and lack of medical documentation. To address this issue, the CSD would need details and all relevant documentation in order to investigate why the claim has not been processed as expected.

QUESTION: I submitted my claim to the insurance company a month ago and still no payment. How long does the insurance company have to pay my claim?

ANSWER: Under Georgia law an insurance company must pay, deny or request additional information within 15 working days of receipt of the claim. Once the insurer has all the information needed to justify payment, the insurer has 15 working days in order to process payment.


QUESTION: The insurance company had everything needed to pay the claim 2 months ago but still have not paid. Is there a law that requires the insurer to pay a penalty for not paying in a timely manner?

ANSWER: Yes. Under Georgia law an insurer must pay a penalty at the rate of 18% per annum on the amount of the unpaid claim beginning on the 16th working day up until the claim is paid.


QUESTION:The insurance company paid my claim and then had the doctor refund the money back because they say it should not have been paid. Can they do this?

ANSWER: Yes, an insurer can generally audit paid claims as long as the audit is completed within 18 months of the date of the service and the claimant is notified of the payment or refund due.

COBRA?

There was a time when group health insurance may have been terminated when a worker lost his job or changed employment. That changed in 1986 with the passage of health benefit provisions in the Consolidated Omnibus Budget Reconciliation Act (COBRA). Now, terminated employees or those who lose coverage because of reduced work hours may be able to buy group coverage for themselves and their families for limited periods of time.

QUESTION:How do I know if I’m eligible for Cobra?

ANSWER: Contact the U.S. Department of Labor @ 1-866-444-3272


QUESTION:I’m having problems getting claims paid & receiving my premium notices under Cobra coverage. Who do I contact?

ANSWER: Contact the U.S. Department of Labor @ 1-866-444-3272

Federal Stimulus – Group Coverage Continuation Subsidy

On February 17, 2009, the President signed the American Recovery and Reinvestment Act, commonly called the Stimulus Plan. The new law provides a subsidy that may reduce, by 65%, the cost of COBRA or Georgia state group health continuation insurance coverage for workers who lose their jobs.

Click HERE to view frequently asked questions abou the stimulus package.

Complaints about a company

Consumers will reach an agreement with the insurance company as to the dollar value of the claim but the repairer has not repaired the car properly. This can cause obvious problems as consumers must in the final analysis contract with a repairer as carrier will not and is not required to do so. Following are some useful resources:

Continuation

Most people are aware that COBRA helps you continue your health insurance coverage for at least 18 months when you lose your job. However, COBRA is only applicable if the employer has 20 or more employees. In Georgia we have continuation coverage for employers that have less than 20 employees. This coverage is a continuation of your previous coverage that lasts for the remaining days in the month that you lose your coverage and then for 3 full months. In order to qualify you must have had coverage under the policy for at least 6 months.

QUESTION:I work for an employer that has less than 20 employees. He is about to cancel all of the health insurance coverage for the company. Will I be eligible for Georgia Continuation?

ANSWER: No. Since the plan is being completely cancelled there will be no coverage available. However, you may be eligible for conversion or Assignment.


QUESTION:Does the Georgia Continuation coverage count as Creditable Coverage?

ANSWER: Yes. All Group and Individual policies count as Creditable Coverage.


QUESTION:I lost my job on the 16th of the month how much coverage time can I have under the continuation policy.

ANSWER: Your continuation policy will cover you for the remainder of the month after the 16th then for an additional 3 months. Your total coverage time will be approximately 3 ½ months.

Conversion

In order to qualify for both plans you must meet the following guidelines:
  1. Complete COBRA if it is available
  2. Must be a Georgia citizen
  3. You must have 18 months of creditable coverage
  4. You cannot be eligible for any other plans.

QUESTION:How do I know if I am covered by a self-insured plan or a policy issued in Georgia (fully insured plan)?

ANSWER: Contact your employer or the insurance company involved. They can usually tell you the status of your health insurance plan.


QUESTION:I was covered under COBRA but the employer I worked for went out of business. The health insurance plan I was covered under also ceased. I was only covered under COBRA for 11 months. Does this mean I will not be eligible for Assignment/Conversion?

ANSWER: No. You will still be eligible for Conversion/Assignment. It does not count against you when the policy terminates. However, if you are eligible for COBRA and you cancel this coverage early, you will not be eligible for Conversion/Assignment.


QUESTION:I have been told I need a Certificate of Creditable Coverage in order to be assigned. What is this and where can I get it?

ANSWER: The Certificate of Creditable Coverage is supplied to you after you have completed your coverage. This form details the dates you were covered under the plan and if there were any gaps in coverage. The COBRA administrator, employer or insurance company will usually supply you with this document. You should receive it soon after your coverage ends but if you do not you can contact them and request that they send it to you.

Coordination of Benefits

All insurance contracts contain this provision which coordinates or reduces the benefit payable if the insured has other comparable insurance in force. Which coverage is primary or pays first depends on various factors including whether the claimant is covered as an employee or dependent, birthday of parent and wording of Coordination of Benefits provision.

QUESTION:I have insurance through my work and I am also covered under my spouse's coverage where he/she works. My insurance paid 80% of the medical bill. I submitted the other 20% for payment to my spouse's group plan and they refused to pay anything. I carry 2 policies so that all the medical bills will be paid. How can the secondary policy deny payment of the balance of the claim?

ANSWER: Under Georgia Insurance Regulations, the secondary insurer only pays if the benefits under the secondary policy are greater than the benefits paid under the primary policy. If the benefits are greater under the secondary policy, the amount paid would only be the difference in the amount payable under the secondary versus the amount paid by the primary policy. In short, if the secondary policy pays equal to or less than the primary policy, nothing is paid by the secondary policy.


QUESTION:Which policy pays first for children when both parents work and have separate group insurance plans?

ANSWER: The “birthday rule” applies which designates the benefits of the plan of the parent whose birthday falls earlier in the year as the primary plan. If both parents have the same birth date, then the plan which has been in effect the longest will be primary.

Employee Retirement Income Security Act — ERISA

Employer Issues

Employees dissatisfied with the manner in which the employer is administering group benefits made available to all employees. Such issues include open enrollment, eligibility for health insurance, payroll deduction, Cobra, retirement benefits, etc.

QUESTION:My new employer says I have to wait 6 months before I am eligible for health insurance benefits. Can they do this?

ANSWER: Yes. The employer can establish eligibility guidelines and waiting periods that are consistent with fair employment practices and U.S. Department of Labor.


QUESTION:My job was terminated in the middle of the month and the employer deducted premium from my paycheck for health insurance on the first of the month. Shouldn’t my health insurance continue until the end of the month?

ANSWER: Not necessarily. The employer generally cancels the health insurance on the same date that the employee is terminated. There is no requirement to refund any premium as it is considered fully earned when paid.

HIPAA (Health Insurance Portability and Accountability Act)

A federal law enacted in August 1996 which limits exclusions for pre-existing conditions, prohibits discrimination against employees and dependents based on health status, guarantees renewability and availability of health coverage to certain employees and individuals and protects employees who lose group health coverage by providing access to an individual health policy.

QUESTION:I’m considering a new job but my wife is pregnant and I have a pre-existing condition. If I change jobs, will the new employer’s health plan provide immediate coverage for my wife’s pregnancy and my pre-x condition?

ANSWER: Yes. Under federal and state law, pregnancy cannot be treated as a pre-x condition and other pre-x conditions will be covered immediately provided you were previously covered under a health benefit plan for at least 12 months and the gap in coverage from the old plan to the new plan is not over 63 days.


QUESTION:Under HIPAA, what types of health insurance contracts are guaranteed issue?

ANSWER: Employer sponsored small group policies (2 to 50 enrollees) and individual conversion policies which are policies available to an individual who has exhausted employer sponsored group coverage, Cobra, Georgia continuation and who is now eligible to convert their group or Cobra coverage to an individual policy. The individual policy must be applied for within 63 days of the termination of the group or Cobra termination.


QUESTION:My individual health insurance policy is guaranteed renewable due to HIPAA but I just received a notice that my policy was being cancelled. Can they do this?

ANSWER: Individual and group health insurers can cancel coverage under certain circumstances. Generally, a policy may be cancelled if the insurance company withdraws a particular policy provided a 90 day written notice is given and other policy forms being issued are offered to the insured. If the insurance company withdraws all policies from the state, a 180 day notice of cancellation must be given and the insurer is precluded from issuing such policies in Georgia for 5 years.

Legal and Statutory Questions

The Insurance Commissioner’s Office enforces and regulates the laws enacted by the state legislature under Title 33 of the Official Code of Georgia. Consumer inquiries are reviewed to determine if the insurer and agent are in compliance with these laws and with the terms and conditions of the insurance contract.

Licensing

QUESTION:How can I know if an insurance company or agent is licensed to operate in Georgia?

ANSWER: Contact the Consumer Services Division of the Insurance Commissioner’s Office at 404-656-2070. An investigator can advise you if the insurance company is licensed, when the insurance company was licensed to transact insurance in Georgia and what lines of insurance the company is authorized to sell. The same information can be provided regarding insurance agents.


QUESTION:Why is it important to purchase insurance from a company licensed to transact insurance in Georgia?

ANSWER: To obtain a license in Georgia, insurers must meet certain capital and surplus requirements deemed essential for performing prompt and reliable claims service for Georgia consumers. Also, should a licensed insurer become bankrupt, Georgia policyholders would be protected by the Georgia Life & Health Guaranty Association for up to $100,000.00. Georgia citizens insured by unlicensed health plans are not eligible for payments under the Life & Health Guaranty Association.

Medical Necessity

Medical necessity is a term used to refer to a course of treatment seen as the most appropriate for a specific injury or sickness based on accepted current medical practice

QUESTION:My doctor says this procedure is medically necessary. The insurance company states it is not. What can I do?

ANSWER: The Commissioner’s Office is not empowered to arbitrate what constitutes “proper or best course of medical treatment” issues. Such matters involve questions of medical fact that only medical professionals can effectively mediate. You will need to follow the appeals process of the insurance contract.

Medicare

Medicare Supplement

A Medicare Supplement or Medigap policy is a health insurance policy sold by a private insurance company to fill the “gaps” in Medicare Parts A and B. These policies are regulated by the Office of Commissioner of Insurance. You may view MEDIGAP rates by clicking HERE.

QUESTION:How can I know which company provides the best coverage?

ANSWER: No company has a coverage advantage over the other. There are 10 standard Medigap Plans (Plans A through J) that insurers may offer. All insurers that offer Medigap policies in Georgia must offer Plan A. All other plans may or may not be available by an insurer.


QUESTION:Can I be turned down for Medigap coverage?

ANSWER: Not if you apply during open enrollment which is a period of 6 months that starts when you are both age 65 or older and enrolled in Medicare Part B.


QUESTION:Should I enroll in Medicare Part B and start my Medigap Open Enrollment Period if I am age 65 or older and still working?

ANSWER: You can wait to enroll in Medicare Part B if you or your spouse are working and have group health coverage through an employer or union. The Medigap Open Enrollment Period won’t start until after you sign up for Medicare Part B. Remember, you must be age 65 or older and enrolled in Medicare Part B to trigger the 6 month Open Enrollment Period.


QUESTION:Why do premiums vary from one company to another for the same coverage and what factors will affect my rate?

ANSWER: Premiums can vary significantly due to the loss experience and operating overhead of each respective company. Factors that influence your premium include: sex, smoker, marital status, health status, coverage features and where you live.


QUESTION:I have a Medigap policy but I am shopping around to see if I can get a better deal. What factors should I consider to avoid a mistake?

ANSWER: Do not cancel your current Medigap policy until you’ve received your new policy and reviewed it thoroughly during the 30 day free look period. If the new policy is not an improvement in what you expected, just return it within 30 days of receipt and continue your old policy. Also, be sure the health questions on the application for the new policy are answered accurately. If the insurer later finds that one or more questions were not answered accurately, the insurer can rescind coverage and refund your premium.

Military Health System (TRICARE)

Network Issues

In an attempt to gain more control or predictability of the cost of medical care and to provide a more affordable alternative to indemnity type contracts that pay claims according to usual, customary and reasonable constraints, insurers introduced managed care. Though various forms of managed care have been around since the turn of the 20th century, a concerted effort by business and fostered by the federal government in the 1970’s has resulted in over one fourth of the population in America being covered under a managed care arrangement. In short, managed care is a term used when referring to HMO (Health Maintenance Organizations) and PPO’s (Preferred Provider Organizations). Both arrangements establish networks of medical providers who are under contract to perform medical services at pre-determined fees for insureds covered under the managed care policy. HMO’s and PPO’s differ, however, in the manner in which insureds share the cost of medical care and how much liberty the insured has to go outside of the managed care network and still receive coverage under the managed care contract.

QUESTION:What is the difference in a PPO and an HMO?

ANSWER: Cost sharing and open access to network medical providers are the main differences. Under PPO’s, the insured generally pays a calendar year deductible and then 20% of the PPO fee. The insured can go to any doctor within the PPO network and receive full benefit and go outside the network and receive a reduced benefit. Under HMO’s, the insured pays a copay each time medical care is rendered. The insured cannot go to any doctor in the HMO network but must coordinate all medical treatment through a primary care physician that is chosen by the insured. Any treatment received outside the HMO network is not payable, unless approved prior to the visit by the HMO.


QUESTION:I have an HMO and my surgery was coordinated by my primary care physician who scheduled surgery in a hospital in the HMO network. I paid my required co-pay but now I am receiving bills from the anesthesiologist and radiologist because they are not in the HMO network. My surgery was done by a network doctor in a network hospital. Now why am I being charged by these ancillary medical providers?

ANSWER: Unfortunately, some ancillary medical providers, i.e. radiologist, anesthesiologist, pathologist, etc., choose not to join managed care networks. Because insureds reasonably assume that if the hospital and surgeon are approved by the HMO, that other ancillary providers will also be covered, most HMO’s will pay these extra fees. Refer these unexpected medical bills to your HMO for payment. If you have any questions or problems regarding this issue, please contact the CSD at 404-656-2070 or website.


QUESTION:What do I do if I have to go to an emergency room that is not in my PPO or HMO network?

ANSWER: If you have an emergency which is a medical condition manifested by symptoms of such severity that the failure to provide immediate care could reasonably be expected to result in placing the patient’s health in jeopardy, impairment to bodily functions or dysfunction of any bodily organ or part, then go. Your managed care plan will pay the bill according to the level of benefits you would receive if you went to a network emergency facility, provided you do require emergency care.


QUESTION:Do I have to go through my primary care doctor to see any medical specialist?

ANSWER: You do not need to coordinate with your primary care doctor to see an obstetrician, gynecologist or dermatologist as long as they are in the HMO network. All other specialists must be coordinated by your primary care physician.

Portability

One of the main reasons for passage of the Health Insurance Portability and Accountability Act (HIPAA) was to make it easier for consumers to move or be portable from one health insurance plan to another without the worry of having to meet another pre-existing exclusion period (usually 12 months). This is accomplished by giving consumers creditable coverage for the time they have already been covered under a health insurance plan. Creditable coverage reduces or eliminates the amount of pre-existing time you will spend under a new policy. In order to receive credit for prior coverage you cannot have a lapse in coverage of more than 63 days on out of state issued or self-funded policies or 90 days for a Georgia issued policy. Group, individual, Medicare and Medicaid are all considered creditable coverage.

QUESTION:I was covered under an individual policy for 8 months prior to being hired by my new employer. I am now covered under the group insurance policy for my new employer. What will be the length of my pre-existing period?

ANSWER: Since you have 8 months of creditable coverage, your pre-existing exclusion period will be reduced to 4 months.


QUESTION:I worked for three different employers over the past 4 years. There were times in between each health insurance plan for each employer that I had no health insurance but the times without coverage was never more than 30 days. Will this reduce my creditable coverage period?

ANSWER: No. Since the times between each plan were less than 63 days it will not change your creditable coverage time.


QUESTION:I am presently covered under an individual policy that has increased in premium by 50% over the past two years. I am familiar with the HIPAA laws concerning portability and thought that I could transfer to any individual policy as long as I had the appropriate amount of creditable coverage time. I applied with a company for an individual policy and was turned down. Can the company do that?

ANSWER: Portability is only applicable when you are changing from group to group coverage or in some cases when you are transferring from group to individual. It does not apply when you are changing from one individual policy to another.

Provider Complaints

QUESTION:I think the doctor has billed my insurance company for services rendered even though I’ve already paid the bill in full. What should I do?

ANSWER: Contact the insurance company so appropriate steps can be taken to confirm whether this has occurred. If so, the insurance company will determine if further action is warranted and whether the medical provider should be reported to the Enforcement/Fraud Division of the Insurance Commissioner’s Office for further investigation.


QUESTION:I have an HMO and I am not happy with the care received by one of the doctors in the HMO network? What can I do?

ANSWER: Contact the HMO and provide specifics regarding why you are dissatisfied with a particular doctor. The HMO re-evaluates network members periodically to determine the quality of care provided and overall patient satisfaction for a given provider. Multiple complaints will alert the HMO to re-evaluate a provider sooner and take appropriate action. In addition, the Georgia Department of Human Resources regulates and reviews quality of care issues by medical providers in HMO networks. To contact the Georgia DHR call 404-657-5550.

Self Funded

This is a medical expense benefit plan sponsored by an employer for employees. Benefits payments are funded directly by the employer rather than an insurance carrier. Thus, no insurance policy contract exists. The employer provides a description of coverage to the employees, rather than an insurance certificate. Copies of the plan documents should be requested from your employer. This means that your plan of coverage is not subject to the insurance laws of the state of Georgia.

QUESTION:I have a self funded health plan & my claims are not being paid. Who can I go to for help?

ANSWER: Self-funded/insured plans are subject to the jurisdiction of the U.S. Department of Labor in accordance with the 1974 Employee Retirement Income Security Act, known as ERISA. You can reach the U.S. Department of Labor at 404-302-3900 or toll-free 1-866-444-3272. Also, the employer is the claims fiduciary; thus, the authority for final determination of any issues involving the payment or non-payment of claims rests with the employer. The employee is entitled to appeal any denial of benefits to the employer, under the provisions of ERISA.


QUESTION:How do I know if my group health plan is self-funded?

ANSWER: Contact the Human Resources Manager of your employer.


QUESTION:I submit my claims to an insurance company. Doesn’t that mean that my health plan is not self-funded?

ANSWER: No. Many self-funded health plans will hire an insurance company to administer their self-funded health plan. Check with your Human Resources Manager.

State Health Benefit Plan (For State Employees, Teachers, School Service Personnel, Retirees and Certain Contract Groups)

All options offered under SHBP are self-funded. For more information, go to State Health Benefit Plans.

Usual Customary and Reasonable

This is a standard method used by insurance companies to determine the amount payable under an indemnity type health contract, e.g. insurer pays 80% and insured pays 20% for covered medical services. The UCR charge is derived by applying claim data and current medical fee levels in a given geographical area.

QUESTION:The doctor charged $3,500.00 for a medical procedure and insurance company only paid $2,000.00 because they say this is the UCR amount. Can they do this and do I owe the difference?

ANSWER: Unfortunately, the answer is yes. Medical fees do not always follow “rational” patterns and medical providers are free to charge according to their own fee schedule. To ensure rate stability and uniformity of coverage, UCR fees are established and serve as the maximum allowable charge for all insureds.


QUESTION:Is there anything I can do to reduce or eliminate the difference in the UCR allowed and the actual doctor charge?

ANSWER: You can appeal to the insurer to re-evaluate the UCR amount allowed. The insurer may be able to justify additional payments and may also contact the medical provider to reach a compromise fee.


QUESTION:Can I buy a policy that does not pay according to UCR so that I will not have to pay the difference charged by the doctor and allowed by the insurer?

ANSWER: Managed care policies (HMO & PPO) pay according to a pre-determined fee agreed upon between the insurer and the medical provider. Thus, the doctors charge will be paid by the insurer except for the deductible, coinsurance or copay owed by the insured.

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