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Warning – Some Things Your Health Policy Will Not Pay For

September 23, 2016 by helpinsureus

There are Certain Types of Medical Treatment Not Covered by Your Health Policy

When a serious medical need arises there are often multiple stages that one goes through on the path to recovery. For instance, a stroke victim may stay in a hospital for several days but then will be released to either the care of a family member or to a skilled care facility. Why? There is an indefinite period of time after a stroke that a stroke victim needs assistance with many daily activities. The hospital stay is part of health insurance. The assistance with daily activities is not part of a health insurance policy.

Example of possible needs beyond health insurance

  1. Acute Care – medical care aimed at treating physical problems directly in an attempt to permanently cure or control them. This is typically covered under a health policy.
  2. Skilled Nursing Care – services for those who require ongoing medical or nursing care; or rehabilitation services for the rehabilitation of injured, disabled, or sick persons. Some health insurance policies offer limited care in a skilled nursing facility, typically 20-60 days. Some do not include coverage for it at all.
  3. Long term care (LTC) – This type of care is not part of a health insurance policy. Insurance coverage for this is called LONG-TERM-CARE insurance. The goal of LTC is not to cure an illness, but to allow an individual to attain and maintain an optimal level of functioning. This type of care is designed to meet the medical, personal, and social needs of those who cannot fully perform many daily activities. When something happens that limits a person’s ability to carry out basic self-care tasks, LTC is needed. (The average annual cost to care for someone with a LTC need is between $30,000 and $70,000 annually. That’s why we all should have some type of LTC insurance coverage.)


Top 4 Ways to Prevent Health Insurance Claims Problems

November 29, 2012 by helpinsureus

Of the many health insurance companies I represent, the following guidelines are valid for each. Here are four steps you can take to help minimize any “claims surprises.” Follow these steps and you may be stress-free.

  • Never rely on the assumption that a certain benefit is covered or that a particular health provider belongs to your HMO or PPO. Always double-check on whether the benefits, services or providers you need are covered before you go to get treatment. You can do this by calling your health plan’s customer-service department. Remember to take notes. Get the representative’s name and write it down, along with the date, time and general details of your conversation.  Keep these notes with your policy. If a claim problem arises and you need to file a grievance, these notes will come in handy. Most insurers customer-service phone calls are tape recorded. Having the date and time of your call will make locating your call history with the representative much easier.

  • Should you have a problem with a claim, call the insurance company CLAIMS DEPARTMENT and ask for an explanation. Again, remember to take detailed notes.

  • If the explanation is not consistent with your understanding of your health benefits, call your agent. Because of their position and their greater knowledge of the health plan details, they might be able to quickly resolve your problem.

  • If you have a claim problem that’s unresolved, file a grievance with your health plan. If you get a denial, don’t give up. In many states, the complaint eventually goes before a state sponsored grievance committee that’s outside the plan (an “external review”) or a “peer review committee” of other health care professionals. There’s always a chance the denial might be reversed.

Otherwise, your health plan is regulated by your state’s insurance department. Your state has a complaint procedure that will trigger an investigation into your problem.
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