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Health Insurance Frequently Asked Questions
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Employment-Related Health Insurance
1. If I leave my employment, when is my employer allowed to take me off the group health plan?
6. Legally, what is the limit on the group insurance pre-existing condition exclusion?
Pre-Existing Conditions
8. What kind of proof do I need to show my new plan to reduce my exclusion period?
Buying Health Insurance
12. I want to buy the Washington Basic Health Plan insurance. How do I go about it?
Existing Health Insurance
16. The hospital is demanding that I pay its entire bill right away. What are my rights?
17. I believe my health-care professional provided incompetent services. Who can I call for help?
Answers to FAQ’s
1. If I leave my employment, when is my employer allowed to take me off the group health plan?
Generally, health insurance ends either on your last day of work or the end of the month in which you last worked. Review your benefits booklet to find out exactly when your coverage ends or check with your employer’s human resource office.
2. According to federal law, how long can my family stay on my employer’s plan after I leave my employment?
Generally, you may stay on the plan on a self-pay basis for 18 months. Read the COBRA overview for basic information. You can find additional information and answers to questions about your rights under this federal law in the U.S. Department of Labor’s (DOL’s) COBRA brochure. To order a copy, call DOL’s Publication Hotline at 1-866-444-EBSA (3272).
3. My plan has denied my claim for a benefit that is mandated under Washington state law. My employer says he doesn’t have to comply with state law because his plan is self-funded. Is my employer correct?
Yes. If your employer self-funds the plan and contracts with an insurance company to provide administration services only, then under the Federal Employee Retirement Income Security Act (ERISA), your employer’s plan is exempt from many state requirements.
However, you have a right to appeal any decisions of the plan. Your appeal rights in your employee benefits plan are required by ERISA. Generally, you have 180 days to file an appeal about any decisions the plan administrator makes. The plan then has 60 days to respond in writing to your appeal.
For complete information about your appeal and other rights under federal employee benefit laws, contact DOL’s local office in Seattle at (206) 553-4244 or call their Publications Hotline at 1-866-444-EBSA (3272). You can also visit them on the Web at http://www.dol.gov/ebsa.
4. I want to change jobs. Can the new employer’s plan deny me coverage because of a health condition?
Your employer’s group health insurance plan cannot deny you or your dependents coverage based on medical history. You cannot lose your insurance just because you get sick.Also, insurers cannot charge you more money based on your health or past insurance claims.
5. If I get health insurance through my employer, is there a federal law that limits how my plan will exclude my pre-existing condition?
Yes. The Health insurance Portability and Accountability Act (HIPAA) of 1996, limits the pre-existing conditions that health insurance plans can exclude from coverage.
The only pre-existing conditions your insurance plan may exclude are for those you received or someone recommended you receive medical advice, diagnosis, care, or treatment during the six months prior to your enrollment date. Your enrollment date is your first day of coverage, or if there is a waiting period, it’s the first day of your waiting period (typically, your date of hire).
If you had a medical condition in the past, but you have not received any medical advice, diagnosis, care, or treatment for it within the six months prior to enrolling in the plan, your old condition is not considered a pre-existing condition. As a result, an exclusion does not apply.
Washington state law shortened this six-month period to three months for employers with more than 50 employees, and those who offer coverage through an insurance company or an HMO.
6. Legally, what is the limit on the group insurance pre-existing condition exclusion?
For self-funded employers, the federal Health Insurance Portability and Accountability Act (HIPAA) permits health plans to require a 12-month preexisting condition exclusion period.
For large groups (more than 50 eligible employees), state regulated health insurers may require a three-month pre-existing condition exclusion period.
For small groups (2-50 eligible employees), state regulated health insurers may require a nine-month pre-existing condition exclusion period.
7. I changed employment and my new group health plan imposes a preexisting condition exclusion period. How does my new plan determine the length of my pre-existing condition exclusion period?
Under federal HIPAA law, your new plan must reduce your maximum preexisting condition exclusion period by the number of days you had creditable coverage in your last health insurance plan. However, the HIPAA law does not require your plan to take into account any days of creditable coverage that precede a break in coverage of 63 days or more (significant break in coverage).
For example, suppose you had coverage for two continuous years followed by a 70-day break in coverage and you then resumed coverage for eight months. You would only receive credit for the eight months of coverage.You would not receive credit for the two years of coverage prior to the 70-day break in coverage.
For state-regulated large and small group insurance plans, state law lengthens the significant break in coverage to 90 days. However, these plans must reduce your maximum pre-existing condition waiting period
to only the amount of time you had continuous, similar coverage under an immediately, preceding health insurance.
8. What kind of proof do I need to show my new plan in order to reduce my exclusion period?
To make a determination on your exclusion period, plans generally need to receive information about your creditable coverage from a certificate provided by your prior insurance company or HMO.
The insurance company or HMO must automatically give you a certificate of creditable coverage when you lose coverage under the plan. They must also provide you with a certificate if you become entitled to elect COBRA continuation coverage, and when your COBRA continuation coverage ends.
You also have a right to request and receive a certificate from your previous insurance company or HMO within 24 months after your coverage ends.
9. I want to buy an individual health insurance policy. Can the insurance company deny me a policy or exclude pre-existing conditions from my coverage?
Yes. The company can reject your application if your health history is poor. All insurers require consumers seeking individual health coverage to complete a Health Screen questionnaire. The company can also require a nine-month pre-existing condition exclusion period in its coverage.
However, the company cannot require certain people with prior health coverage to complete the health questionnaire. The company must also reduce its pre-existing condition waiting period for certain prior health insurance coverage. For more information on the unique rules of individual plans, see our section on individual health care coverage.
10. My employer has a “waiting period” that must pass before I can enroll in the company’s health plan. How does the employer-imposed waiting period affect the plan’s pre-existing condition exclusion period?
Federal law allows employer-sponsored group health plans to impose a waiting period before coverage takes effect. A waiting period is the period that must pass before an employee or a dependent is eligible to enroll under the terms of the plan.
Some plans have both an employer-imposed waiting period and a preexisting condition exclusion period (see question 5 for the explanation).
If a group health plan has both an employer-imposed waiting period and a pre-existing condition exclusion period, then federal HIPAA law requires that the pre-existing condition exclusion period begin at the same time the employer-imposed waiting period starts.
For example, typically your first day of work is the start of your employerimposed waiting period. If you start work on Jan. 1, 2008 and the plan has a one-month employer-imposed waiting period before coverage goes into effect, then your coverage would begin on Feb. 1, 2008.
If the group health plan has a three-month pre-existing condition exclusion period, this period would end on March 31, 2008, two months after your plan’s effective date.
The health plan would have to give you credit for the month of January because the employer-imposed waiting period and the pre-existing condition exclusion period must run concurrently.
11. I am about to lose my health coverage. I have a serious medical condition and need to get new insurance. Is there a health plan I can buy?
If no other comparable insurance is available to you, then you may qualify for the Washington State Health Insurance Pool (WSHIP). WSHIP provides health insurance for people who are unable to buy individual coverage in the private marketplace.
The plan provides comprehensive coverage, including a prescription drug benefit. For more information, visit WSHIP’s Web site at http://www.wship.org or call 1-800-877-5187.
12. I want to buy the Washington Basic Health Plan insurance. How do I go about it?
Contact the Basic Health Plan at 1-800-826-2444. This program is run by the Washington State Health Care Authority. The Insurance Commissioner does not regulate this program.
13. I need medical care but don’t have enough money to buy insurance. How do I obtain public health services?
The Washington State Department of Social and Health Services manages many public health services. For more information, contact the local Community Service Office (CSO) nearest you. To find contact information for your CSO, visit http://www.adsa.dshs.wa.gov/Resources/clickmap.htm.
14. I have a managed care plan. My primary care doctor won’t refer me to the specialist I need to see. What are my rights?
You can file a grievance. Your benefits book should describe your plan’s grievance procedure. All managed care plans must have a grievance procedure for disputes involving service denial and for dissatisfaction with care. You also have a right to go outside the plan to receive services on a selfpay basis.
15. Is a participating provider in a managed care plan allowed to charge me amounts greater than the insurer will allow?
No. According to state laws and regulations, participating provider agreements do not allow providers to collect any amount other than what they contractually agreed upon with the health insurance plan (RCW 48.80.030(5), WAC 284-43-320).
16. The hospital is demanding that I pay its entire bill right away. What are my rights?
The Federal Trade Commission protects your rights as a debtor under federal law. For more information, call them at toll free at 1-877-FTC-HELP (1-877 382-4357) or visit their Web site at www.ftc.gov/bcp/conline/pubs/credit/fdc.htm.
17. I believe my health-care professional provided incompetent services. Who can I call for help?
To make a complaint about a health professional or hospital, call the Washington State Department of Health (DOH) at 360-236-4700, or visit them on the Web at http://www.doh.wa.gov/hsqa/.
Updated 05/13/2011
Office of the Insurance Commissioner | Phone: 360-725-7000 Free insurance consumer hotline 1-800-562-6900 |
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