Insurance fraud by policy holders and others (09/26/2008)
... - Obtaining the same prescription drugs from several doctors. - False coverage schemes, such as when an “insurance company” accepts your premiums but doesn’t pay your claims. - Substituting a covered diagnosis for a routine checkup. Insurance companies are fighting back to a greater and greater extent. Insurers are diligently pursuing perpetrators of fraud in every way possible, including using special investigative units and high-tech data tracking....

Health insurance plan selection and comparizon (09/26/2008)
... Some families include unmarried domestic partners. Check out your plan’s policies regarding coverage for domestic partners, but don’t be surprised if coverage isn’t available. The issue of health insurance for domestic partners has no national legislation, nor does any state have regulations covering its employees’ domestic partners. To cover a person under your health insurance plan, that person must be considered a dependent. The definition of dependent is based on your plan’s legal requirements concerning financial support....

Take these steps to protect the confidentiality of your medical records (09/26/2008)
... When an individual applies for life, health, or disability insurance, the applicant’s medical records are likely to become part of MIB’s database. Sometimes members of small groups, late enrollees, and applicants requesting additional coverage may end up in the database as well. Insurers pay a membership fee to MIB and a fee each time they verify applicants’ information. Insurers also report individuals’ medical conditions to MIB to add to its database. When you apply for an insurance policy and the insurer checks with MIB, you may end up paying higher premiums because of information MIB reports to the insurer....

Health insurance companies usually have their own claim forms (09/26/2008)
... If you already paid your provider and want the insurance company to reimburse you, don’t sign the assignment of benefits. Claim forms indicate what information you need to fill in and which information your provider needs to enter. The patient or policyholder usually fills in the following information: Name of policyholder, address, and Social Security number Name of the insurance company, group number, and the policyholder’s ID number Patient’s name, address, date of birth, sex, and relationship to the policyholder Patient’s marital status and work status (employed or student) Employer’s name and phone number Whether the claim is due to an injury; if so, date of injury and whether the injury occurred at work Name, address, and phone number of other insurance company covering patient Whether the patient has Medicare coverage Signature to authorize release of information and assignment of benefits When you sign the authorization to release information, you’re giving the insurance company the right to get any and all information relevant to your claim from your health care providers. Either the patient (or policyholder) or the health care provider may have to fill in the following: Date of first sign of illness, or date of accident Date of previous instance of same or similar illness Dates the patient is unable to work in current occupation Name and ID number of referring physician Hospitalization dates The health care provider usually fills in the following: Diagnosis or nature of illness or injury Dates of service, procedures, and charges Federal tax ID number Patient account number Whether the provider accepts assignment of benefits Amount paid and balance due Provider signature and date Double-check that all information you enter on the claim form is legible and correct. Sign and date the form....

Check your health insurance policy for the appeals process (09/26/2008)
... If the insurer continues to deny benefits, submit copies of the claim, correspondence, notes, and the relevant pages of your policy to your state’s insurance department. Remember to include your policy or claim number. Write a cover letter explaining in detail why you think the insurer did not properly pay benefits for your medical expenses. The department of insurance notifies the insurance company of your complaint. The insurer must then respond to the state insurance department within a specified period, usually 10 to 30 days....

Coordination of Benefits COB and Health insurance (09/26/2008)
... Each runs its own federally funded CHIP program, so the programs vary. States must ensure that CHIP funds only cover children who are currently uninsured. Find out how CHIP affects you. Call the toll-free number, 877-543-7669, to find your state’s toll-free CHIP phone number. Keeping Good Records With accurate, up-to-date records, filling out the claim form (a request to pay your medical expenses) should be simple and painless....

Medigap and Medicaid insurance policies regulated by Government (09/26/2008)
... Plans A through J represent a wide range in coverage. Plan A offers the most basic supplement to Medicare coverage. Plan B (not to be confused with Medicare Part B) offers the same provisions as in Plan A, along with additional specified provisions, and so on through Plan J. Plan J offers the most coverage of the Medigap plans and is usually the most expensive. The availability of these plans depends on where you live: Your state may offer all or just a few of the standard policies....

Medical Insurance cover several medical services and items (09/26/2008)
... (An approved charge is the amount that Medicare decides the service is worth. This amount may differ from the actual amount on your bill.) You pay the balance of the hospital’s charges. Medicare pays 50 percent for approved outpatient mental health services, and members pay the balance. Members also pay for all charges for services and supplies that Medicare doesn’t cover....

Original Medicare Plan Covering hospitalization (09/26/2008)
...m. to 4:30 p.m., local time, weekdays. Talk to a customer service representative in English or Spanish for: - General information about Medicare and Medigap insurance - General information about Medicare health plan options in your community - Specific quality and satisfaction information about managed care plans - Telephone numbers for help with billing questions about Medicare claims or other issues After hours, use the automated options to - Order Medicare & You handbooks or audiotapes in English or Spanish - Request updated information about health plans in your area - Hear recorded answers to frequently asked questions Determining eligibility If you’re eligible for Social Security retirement payments, you’re usually eligible for Medicare coverage....

Disability Short term and Long term (09/26/2008)
... In addition to any sick-leave benefits your employer pays, live on your savings or the sale of an investment for a couple of months. Long-term disability (LTD) Long-term disability insurance kicks in when short-term disability ends, usually after 52 weeks. Its goal is to lessen the threat of financial disaster. LTD plans pay monthly benefits from periods of one year up to a lifetime, depending on your plan when disability prevents you from returning to work. Your plan also specifies when your benefits begin, how much you will receive, and any coverage limitations....

Insurance and the Prescription drug card program (09/26/2008)
... If your plan has a closed formulary, and that formulary doesn’t include your drug, check your plan carefully: It may have a provision that lets you request approval for benefit coverage of your drug. Step therapy Health insurance plans also limit the high cost of drugs through step therapy. Step therapy requires plan members to follow a specific progression of prescriptions. You start with the least-expensive medication and then move one prescription at a time toward the most expensive prescription, stopping when your condition is under control. If you already know which prescription drug is successful for you, take action before you join a new plan....

Critical illness insurance and Long Term Care (09/26/2008)
... Some plans, for example, won’t pay for a care provider who is a member of the immediate family. One way to enhance coverage for catastrophic illness is to purchase a catastrophic coverage policy. These policies are designed to pay for hospital and medical expenses that exceed a very high deductible, perhaps $20,000 or more. Such policies may also provide for a fairly high maximum lifetime limit. Another approach is to add a living insurance rider to a life insurance policy....

The dread disease insurance plans pay a fixed dollar amount (09/26/2008)
... Even so, weigh the cost of the policy carefully compared to the benefits it pays before you buy. Shopping for a plan Think about your family history and lifestyle as you shop for a dread disease policy: These factors may help you get a sense of whether you’re at risk for a particular disease. Start by examining plans carefully, because they often exclude coverage for problems resulting from the specified disease itself, such as infections, diabetes, and pneumonia. In some cases, you have to wait several years after you buy a policy before the plan will pay for treatments. Always check the fine print for the following: - All-inclusiveness: Benefits should include expenses for items such as hospital stays, medicine, surgery, doctors’ visits, radiation treatment, chemotherapy, and reconstructive surgery after a mastectomy....

Many health insurance plans exclude dental care (09/26/2008)
... If you’re a member of a dental discount card program, just show your card each time you visit the dentist. Cleaning and X rays Dentists use prophylaxis (teeth cleaning) and X rays to diagnose oral health conditions. Dental insurance plans may cover only a limited number of these services per year. If you choose a dental insurance plan that uses deductibles and coinsurance (as opposed to the discounts that a dental discount card program provides), look for a plan that covers diagnostic and preventive services. Routine restorative care Routine restorative care is a fancy way to refer to dental fillings....

Health insurance Portability and Accountability Act HIPAA (09/26/2008)
... Setting limits for exclusions Under HIPAA, an insurer may apply a pre-existing condition exclusion or waiting period only if it’s for a condition for which medical advice, diagnosis, care, or treatment was recommended or received during the six-month period before your enrollment date. (If you had a medical condition and didn’t receive medical advice, diagnosis, care, or treatment within the six months before your enrollment date, then the condition is not considered to be pre-existing.) An insurer can apply a maximum waiting period of 12 months after your enrollment date. For example, if you received treatment for asthma in October and plan to enroll in a new policy the following January, the asthma may be considered a pre-existing condition and may be subject to, at most, a 12-month waiting period. (Until the waiting period is over, you pay the medical costs for treating the asthma....

Health insurance and Hospital Surgery care (09/26/2008)
... Medical Tests and X Rays Some health insurance plans pay 100 percent of covered charges for routine and diagnostic medical tests and X rays, up to an annual dollar limit. For example, the plan may pay the first $100, after which you pay a deductible and coinsurance. With other plans, you may have to pay first: You pay the deductible and coinsurance, and then the plan pays 80 percent (for an in-network provider) or 50 percent (for an out-of-network provider) of the covered charges. Comparing Accidents to Illnesses If you run a high fever or fall out of a tree, you may visit a hospital emergency room. Both of these conditions is an “emergency” to your mind, and accordingly, you expect your health insurance plan to cover the associated charges, according to the schedule of benefits, a table or list showing the maximum amounts a plan pays for covered expenses....

Health insurance plan covers doctor office visits (09/26/2008)
... Most PPOs also cover preventive care. Maternity Care health insurance plans vary in the way they treat maternity and childbirth expenses. Some policies provide benefits for pregnancy complications but not for normal deliveries. Many policies won’t pay for certain procedures, such as elective cesarean deliveries or abortions. In some cases, you may need to add a rider (a document that changes provisions in the original policy) to your basic health insurance policy to get coverage for prenatal care, normal delivery services, and routine, newborn nursery care (at the hospital)....