Most families in NH get their health insurance through their employer or their spouse’s employer. There are generally two different types of health coverage available through an employer that could cover a family’s medical expenses. It is important to know the difference!
Fully Insured Health Care Plans
When an employer wants to provide health insurance to their employees, they have a number of options to consider. One way to do it is to look at the available plans different insurance companies offer in their state. The employer can decide what type of plan they want and what kinds of benefits their plan is going to have. They then can offer this plan or maybe a choice of plans to their employees. When an employer decides to get insurance in this way, it is called “fully insured”. The New Hampshire Insurance Department regulates fully insured plans since they are an insurance “product” that is sold in the state of New Hampshire.
Self-Insured Health Care Plans
Sometimes an employer, especially if it is a large employer, will decide to pay their employee’s medical bills directly instead of paying an insurance company. This is called “self-insured” or “self-funded”. In these plans it is the employer covering the medical costs and assuming the risks. The employer may decide to have an insurance company administer the plan, that is bill for premiums and handle paperwork, so it may look just like a “fully insured” plan. There may even be an insurance company’s name on the paperwork and on the insurance card.
You will need to ask the person who handles insurance at your work to find out if it is a self-insured plan. This is important because this type of insurance is not regulated by the state’s insurance department as it is not an insurance “product” that is sold in the state. Instead, it is regulated by the Department of Labor and while it has to follow federal laws (see ERISA on sidebar), it does not need to follow state laws. An example of this is “Connor’s Law”, a bill that was passed in New Hampshire requiring insurance companies to provide coverage of certain Autism therapies, such as Applied Behavior Analysis (ABA) therapy. Since Connor’s Law is a state law, it only applies to insurance products sold in the state of NH. For more information on Conner’s Law see the document on the sidebar.
Learn More About Your Health Plan
It is important to understand the health insurance plan you receive from your workplace and how to use it. The information below will assist you in this process. For definitions of any of the terms below in bold, Check out Alphabet Soup on the sidebar.
When you receive your plan, and every time it is renewed, you should obtain from your employer information that tells you about the plan. Your employer should give you information about how much the plan costs per month (the premium), how much they contribute to the cost per month and how much you will have to pay. The amount you pay is usually taken out of your paycheck automatically.
Your employer will also provide you with a plan description, sometimes called a Summary of Benefits. This document will give you a brief overview of what the plan covers and what other costs you might have to pay besides the premium. You should also request a copy of the policy or the Certificate of Coverage which will give you more detail about your coverage and costs.
It is important to know if your insurance requires you to see doctors in-network or not, and whether your doctor is in this network. If your doctor is not part of the insurance plan’s network, you can call your doctor and ask them if they would consider contracting with your new insurance. If not, it is important for you to know your plan’s policy on out-of-network providers.
You may be required to get a referral, a written order that is usually submitted electronically from your primary care doctor to the insurance company in order for you to see a specialist or get certain medical services. With some plans, you need to get a referral before you can get medical care from anyone except your primary care doctor. If you don’t get a referral first, the plan may not pay for the services. Some plans also require that you get prior authorization before you see a specialist or receive certain services. It is a decision by your health insurer or plan that a health care service, treatment plan, prescription drug or durable medical equipment is medically necessary. If a service requires prior authorization and you do not get one, the plan may not pay for the service.
When you look at your insurance information, find out when the enrollment period is and when the plan renews. Your insurance coverage is generally for one year. If you meet your deductible before the renewal date, insurance will pay for covered services, less any coinsurance amounts. With this information, you will know what you will be responsible for ahead of time.
Some plans have co-pays, a set amount you pay when you see providers or have services. The co-pay can vary depending on who you are seeing and is usually not included in your deductible. The Summary of Benefits information will tell you when there is a co-pay and how much it is. It is important to know that not all plans have co-pays. Depending on your plan, you may be responsible for the whole visit amount until your deductible is met, such as with High Deductible Health Plans (see fact sheet on sidebar).
Most health insurance plans send out a document called an “Explanation of Benefits” or an EOB after you have visited the doctor or had some other kind of appointment. Sometimes these are available online. The EOB contains information about your plan that is specific to you and the services or appointments you have had. There generally is a descriptor of the appointment (i.e. Office visit), the code it was billed under and the date of service. The EOB will tell you what the plan will pay and what they say you should pay. If you think there is an error, call your insurance company and find out why it was billed the way it was billed. Often it is just a mistake that can easily be corrected. Remember to NEVER make payments based on the information on an EOB. ALWAYS wait for a bill from the provider.
What to do if Your insurance Won’t Pay
Private health plans may deny a claim. Do not be surprised or discouraged if this happens. This will show on your EOB as your responsibility to pay the provider, or how much you owe. If this happens and you feel it is in error, seek clarification. Sometimes it is as simple as resubmitting the claim. Talk to your insurer and find out.
If the insurance company has decided to deny the claim, maybe you should consider making an appeal. With every EOB, you should receive notification of what to do if you do not agree with the insurance company along with information on how to file an appeal. You can also call the insurance company and ask them the process to appeal. Generally, there are first, second and third level appeals. The first is usually an internal review done by people who were not involved in the original decision. If the claim is still denied, you can request an appeal again, and again it will go to different people within the insurance company. In NH, at the same time you are making these appeals, you can ask the NH Insurance Department to help you with an external appeal. They will do this for any plan in NH that is a fully insured plan. Here it is important that you know about your health plan.
You can call the NH Insurance Department at (1-800) 852-3416. Remember when filing an appeal to do everything in writing, to keep copies and to be aware of time limits. If you wait too long, you may not be able to appeal.