Health Insurance Questions & Answers
Q. I just started my job, when should I enroll for my insurance?
A. New hires have a waiting period before they are eligible for benefits. This is typically 30 to 90 days and benefits start the first of the month following that period. You should talk with your administrator and try to have your application in at least 30 days before your effective date. This will ensure you are covered as soon as you are eligible.
Q. What happens to my health insurance if I change jobs?
A. You will have the option to continue your medical coverage for a period of 18 months under the COBRA rules if your employer has 20 employees or more. Your employer or the carrier will contact you regarding your eligibility and the costs involved. If you work for a small company (less than 20 employees) you are eligible to continue your coverage for a maximum of 120 days under Arkansas Small Group Continuation law.
Q. Why shouldn’t I use “out of network providers”?
A. Managed care has greatly reduced the cost of medical procedures by setting limits on how much can be charged for each procedure. When you use a participating provider you are guaranteed the best possible prices for treatment and do not have to worry about balance billing. If you go to a non-participating provider several things happen; your deductible is usually increased, the co-insurance you pay is also greatly increased but more importantly, you are billed for total difference in what the insurance would have paid a participating provider. This amount does not stop when you hit the “out of pocket” limits. You should never use a non-network provider unless you have negotiated a fee schedule in advance and have it in writing. This can cost you a tremendous amount of money.
Q. Will my pre-existing health condition be covered?
A. HMO plans generally do not exclude pre-existing conditions. PPO plans usually do exclude pre-existing conditions for up to twelve months. However, if you recently had other health insurance coverage, you may be able to use the Certificate of Creditable Coverage (“HIPAA certificate”) issued by your previous carrier or employer to have all or part of the exclusion period waived. You should submit your HIPPA certificate with your enrollment form or forward it to the new carrier as soon as possible after you enroll.
Q. Can pregnancy be excluded as a pre-existing condition?
A. No — Not on group health plans.
Q. What do I do if a claim has been rejected?
A. Call the Member Services number on your ID card. Be sure to have your ID number and the Explanation of Benefits (EOB), provider bill on hand when you call. Always record the date and time of your call and the name of the person you speak with. Many times claims issues can be resolved with one call.
Q. I did not enroll [enroll my dependents] in the health plan when I was hired. Can I sign up now?
A. The general rule is that you must wait until your plan’s next open enrollment period. There are certain situations that allow you to join the plan midyear. Getting married, divorced, having or adopting a child, an involuntary loss of medical coverage and a spouse changing jobs are the primary status changes that allow you to join mid-year. You will have 31 days to apply for coverage with these credible events.
Q. I have just had a baby [gotten married, adopted a child]. What do I have to do to cover my new family member?
A. The new family member is NOT automatically covered, even if you currently have family coverage. You must complete and submit an enrollment form within 31 days of the event. After 31 days, the family member will be considered a late entrant and may not be eligible to enroll until the next open enrollment period.
Questions To Ask Before You Sign Up For Health Insurance Coverage
Q. What type of plan is it?
A. In indemnity health plans, also known as fee-for-service plans, you pay a percentage of the medical costs, and the insurance company pays the rest. Typically, you are allowed to choose any doctor. In a HMO, your benefits are usually richer and out of pocket expenses are lower, but you can go only to a doctor who is under contract with the HMO (a “participating” or “in-network” provider. In a PPO, you may go to a doctor outside the PPO system, but you’ll pay more. POS plans combine both approaches to provide benefits similar to an HMO but with the option to receive reduced benefits out of network.
Q. How much will I have to pay in deductibles, co-pays, etc.?
A. Find out the amount of your deduction per pay period, and whether the company pays for part of dependent coverage. Then, ask how you will be charged for services covered by the plan — by co-payments, deductible and coinsurance. Pay attention to services you and your family use most often, (e.g., office visits, prescriptions) and how you will be charged for them. Ask if the plan has a maximum out of pocket amount and whether total benefits are limited.
Q. When will my coverage take effect?
A. Knowing this will help you make appropriate arrangements for COBRA coverage if necessary, or to postpone optional medical expenses until coverage is in force.
Q. Will I be able to use my current doctors?
A. Ask about any limits on choosing your doctors or hospitals and request a provider directory of doctors, hospitals, and other participating providers.
Q. What benefits are included?
A. Review the summary of benefits and ask about benefits that are of special interest to you and your family. If there is a formulary, check to see how the plan handles prescriptions your family takes. Ask what benefits are NOT covered by the plan.
Q. What happens when I need care away from home?
A. Some types of plans make no provision for care except in medical emergencies when you are out of the plan’s service area. This arrangement may not serve your family’s needs if, for example, you have a college student living away from home or if you provide coverage for a child living with a custodial parent.
Q. How does the plan compare to other coverage available to me (e.g., through my spouse’s employer)?
A. Compare the cost (not just the cost of premiums but your out of pocket cost for services), benefits, the provider network, and how each plan works with the way you and your family use medical coverage to decide in which plan to enroll.
Q. If I don’t enroll now, when will I be able to enroll if I change my mind?
A. Except in special circumstances, many plans will require you to wait until the next open enrollment period if you do not enroll within 31 days of you date of hire or during annual open enrollment. It’s also a good idea to find out when your spouse’s plan will let you enroll.