Individuals and families often require medical services to remain healthy or recover from an injury or illness. The supplies, personnel, and experience needed to provide skilled health care are often times too expensive for these families to pay for alone. Health insurance allows people to pay smaller amounts for these services, but the amounts and sources of coverage are complicated.
The industry has been controversial for some time now and the federal government is trying to find a solution to key issues. There are many federal and state laws to regulate health insurance, and a few are discussed below. The Coye Law Firm can help you defend the rights outlined in these laws. Our health insurance attorneys can inform or protect your rights in the case of an insurance dispute.
Employer Plans vs. Private Plans
Employers may offer health insurance coverage as a benefit to employment. The group rate is cheaper than a private plan, so this can be a great opportunity for anyone who has the option. If you have health insurance through your employer, you can take advantage of the Health Insurance Portability and Accountability Act (HIPAA). This law keeps employer health plans from excluding some preexisting conditions from coverage. Additionally, a condition cannot be excluded for more than 12 months.
Private plans can be more expensive than those offered through an employer, but some individuals and families may not have a choice. The Florida Department of Financial Service has a Web page of tips, lists, and information relating to health insurance available here.
COBRA & Mini-COBRA
COBRA is a federal act that allows individuals and families the opportunity to continue their group health insurance coverage if their circumstances change. For example, if a parent loses their job or is in the process of transitioning to a new one, they may be granted a temporary extension of their benefits for themselves and their family. They are required to pay their entire premium to maintain the coverage, but it is typically cheaper than private health insurance plans. To be eligible, an employee can terminate employment voluntarily or involuntarily or have their hours reduced. Spouses and children are covered under these circumstances and also in event of divorce, legal separation, or death of the covered employee. To claim this coverage, notice has to be received within 60 days of loss of coverage.
Due to economic conditions, the U.S. government temporarily allowed individuals insured under COBRA laws to pay a lower premium. If the individual involuntarily ended employment from September 2008 to December 31, 2009, they may only be required to pay 35% of the premium for coverage. The employer picks up the remaining cost. FAQs about this assistance can be found here.
Florida has it's own version of COBRA for employees. It is very similar to the federal legislation, except for the lower number of employees needed to require COBRA coverage. Federal law states that an employer with 20 or more full-time employees must provide them with the option to continue coverage, but Florida's mini-COBRA allows the coverage for groups smaller than 20 employees. An overview of the differences is available here. The state has listed the agencies to contact if you are interested in filing a COBRA complaint. For mini-COBRA complaints, click here.
erisa is another federal act that allows individuals at retirement age access to health insurance and pension plans. The law does not require that employer offer either of these benefits, but erisa regulates them once they are in place. To learn more, visit the erisa page as it relates to a workers' compensation claim.
For complaints under erisa, including federal COBRA and Retirement plans, visit the Department of Labor's Compliancy Assistance page. There is information about employer and employee responsibilities and mediation procedures, all the way up to the federal reporting process.
Medicare & Medicaid
Medicare and Medicaid are two federally sponsored health insurance programs to assist those in need. Medicare is designed for those over the age of 65 and Medicaid is for individuals and families with low incomes and resources.
Medicare is broken down into four coverage areas, including:
- Part A, which provides for hospital insurance, including brief periods in nursing homes.
- Part B, in which medical insurance is provided, including the outpatient care not covered under part A.
- Part C, which covers "Medicare Advantage plans," allowing medicare recipients to receive benefits through private insurers instead of the federal program
- Part D, which provides coverage for prescription drugs that the individual may need.
Medicaid is managed by individual states. Therefore, rules for participation and coverage are different depending on where the individual lives. The program is offered to lower income individuals and families, but still has strict requirements for coverage. An overview of the program is available at the official website.
Denial of Coverage
Whether your claim is denied or you are completely denied coverage, you may want to consider an appeals process. Insurance companies have different methods of appealing a denied claim. Investigate the specific appeals process if you are still interested in pursuing coverage. Being denied coverage based on factors such as age or gender may fall under discrimination if the insurance company provides no other grounds for denial.
The Genetic Information Nondiscrimination Act was recently enacted and prohibits insurance companies from requiring genetic testing for an individual or their family members when determining the amount and cost of coverage. If you have been required to undergo tests or divulge information on diseases, disorders, or conditions, you may have been the victim of discrimination. The Coye Law Firm is committed to defending these rights to privacy.
If you have filed a workers' compensation, personal injury, or other claim that provides health care benefits, you may have a complicated situation when it comes to the benefits your own health insurance pays for your injuries. It is important to coordinate benefits and notify all sources. You may be able to collect benefits from more than one source if the policies cover different circumstances, but notification may still be required. Failure to do so can result in having to pay back insurance companies and other consequences. Consult an insurance attorney at the Coye Law Firm to make sure that your benefits are within the scope of your insurance policy. Our health insurance lawyers are able to answer extensive questions regarding coverage or payments.
The Coye Law Firm's health insurance attorneys are dedicated to fighting for the rights of consumers involved in insurance disputes. Legal questions can come up through any of these laws and require an experienced health insurance lawyer to sort through. Call our offices today to get resolution for your health insurance claim. Our health insurance lawyers can help you get the benefits or answers you need.