Health Insurance HQ: An Update on the Health Care Landscape

Dear Friends,

This month, we thought we’d address the anxiety many people feel when there’s a problem with their insurance. Maybe your insurer refused to pay for a service, but you think they should have. Issues like this happen – so what can you do?

Tip # 1– Understand your coverage.
Before accessing medical services, understand what is covered by your insurance policy, what isn’t, and the rules of that policy.

• Do you need prior authorizations before receiving certain services?
• Do you need to be referred by your primary care physician to see a specialist?
• Do you have out-of-network benefits?
• Are your medications covered on your plan’s formulary?
• What does your plan specifically not cover?
• What are your co-payments, co-insurance and deductible?

Tip #2 – Know your rights as a consumer
You have the right to obtain detailed information about your plan, to receive quality care and appeal denials of service and claims, and to have your claims paid in a timely manner. Under the Affordable Care Act, your plan must notify you of:

• The reason your claim or coverage was denied.
• Your right to file an internal grievance or an appeal with instructions on how to do so. This may include several levels of an internal process.
• Any deadlines in which to submit your appeal.
• Your right to an external appeal.

Tip #3 – File the right kind of objection
Complaints and grievances are filed when you are dissatisfied with the care or services that you have received from your plan, or some other aspect of your plan. For example, you waited too long for your appointment, or the doctor was rude.  

An appeal is filed when you have been denied services that you have already received, or if you were denied prior authorization for a service. For example, you are requesting to see an out-of-network doctor because the network does not have a specialist in that field.

An expedited appeal is an urgent matter where the insurance company must respond as soon as possible. Plans must make a decision usually within 24 hours, but no longer than 72 hours, from receiving the appeal.  An expedited appeal should be requested if your medical provider believes a delay in treatment could seriously jeopardize your health, or the issue is related to a hospital admission and you have not yet been discharged.

Tip #4 – Take notes and names
If you call your plan, take note of the dates and times of your calls, with whom you spoke and, if you can, get a reference number when possible. Keep all documents received from the plan organized and in one place. You may need to refer to them. If you do not understand or agree with the first representative you speak with, request to speak with a supervisor.

Tip #5 – Request an external appeal
We’ve talked so far about filing complaints and appeals with the insurance company, but effective January 1, 2012, health insurers in all states must also participate in an external review process that meets minimum consumer protection standards as outlined in the Affordable Care Act. An external review is conducted by an independent third-party not related to the plan. If the plan denies an appeal, an external review can be requested. There are two steps in the external review process:

• File an external review: You must file a written request for an external review, generally within 60 days of the date your insurer sent you a final decision. The notice sent to you by your health plan should tell you the timeframe in which you must make your request. It is important to remember that insurance companies (including those on the Affordable Care Act Marketplace) as well as programs such as Medicare, Medicaid and the Child Health Insurance Program, all have timeframes that you must follow when filing a grievance or appeal. Timeframes and regulations can vary by state.

• External reviewer issues a final decision: An external review either upholds your insurer’s decision or decides in your favor. Your insurer is required by law to accept the external reviewer’s decision.

Note! Faith-based plans, short-term plans, and association plans are less regulated and do not offer the same level of rights and protections. If you have one of these plans, ask if they have a grievance and appeals process.

Tip #6 – Get help
The National Association of Insurance Commissioners (NAIC) has an excellent website that gives you instructions on how to file grievances and appeals with your state insurance department.
Some states have organizations that can provide free counseling and assistance. For example:

• In New York, Community Health Advocates (CHA)
• In California, the Office of the Patient Advocate

Your state and local representative may be able to help. When you are preparing your appeal letter, copy (CC) your letter along with the denial letter you received to your state legislator. Not only may you get some assistance, but your health plan will also be aware that you have copied an elected official, and they may act more quickly.

Remember: you do have protections as a consumer. The squeaky wheel gets the grease! If you feel that a decision was made incorrectly…make noise. With documentation. And in a timely manner. But make noise!

Yours in good health,

Do you work in performing arts and entertainment and have questions about health insurance? The Actors Fund provides assistance nationally. Contact our regional office closest to you to speak to a counselor.

New York City
917.281.5975

Los Angeles
855.491.3357

Don’t forget to use the resources section of our website. It contains tools to help you make decisions about your health insurance, including new online tutorials on how to choose providers and how to read an Explanation of Benefits. In addition, you’ll find an updated Stage Managers National Health Directory, our national online directory of health care providers recommended by industry professionals that can be used by theaters and touring companies. For these resources and more, visit actorsfund.org/HealthServices. You can also find out more about enrollment assistance and upcoming health insurance seminars near you!

Photo © Kimberly M. Wang / eardog.com