To join a group health plan you must first be eligible for the plan. For example, though an employer may have a group health plan, it does not have to be open to everyone, perhaps being designed for full-time and not part-time workers. In addition, the plan may be operated by an HMO and you could find that you are living outside of the service area for the HMO.
Assuming that you are eligible to participate in the plan then you have to be permitted to join regardless of your state of health. For this purpose your state of health means your present health, including any disability that you may have, and to your prior medical history. It is also interesting to note that you may not be excluded as a result of genetic information.
It is important to understand here that, in spite of the fact that an employer is allowed to refuse you membership because you do not for example work sufficient hours, he is not permitted to exclude you based solely on your current or prior medical history.
Most plans has an enrollment period during which you must elect to join the scheme which might typically be within about 30 days or joining the company. However, if you choose not to enroll at this stage then an employer is required to give you an opportunity to join during what is usually called a special enrollment period if particular changes arise within your family. These changes might include things like marriage, the adoption of a child and the loss of other medical insurance coverage because of things like the cessation of coverage being provided through another family member as a result of death, divorce, retirement, legal separation, termination, reduction in working hours and similar things.
Almost all plans also normally have a waiting period for membership that will typically be anything from 30 days to about 3 months. This waiting period must be applied consistently for all employees and during this time an employee will not be covered under the group plan.
Where the group plan that you are joining is being run by an HMO then the HMO can also apply a waiting period (generally called an affiliation period) where you will once again not be covered. HMO affiliation periods may not normally be more than 2 months and where a waiting period is applied the HMO may not then impose any pre-existing conditions exclusions.
Under the provisions of Florida law any group health plan that includes dependent cover also has to provide cover automatically for newborn babies, newly adopted children and children who are placed for adoption for 31 days from birth, adoption or placement. The can also require parents to register these children during this 31 day period for cover to continue beyond this point.
For parents taking care of disabled children who are covered under a group plan cover will usually continue beyond the age when a child would no longer be considered as a dependent, provided the parents can demonstrate that the individual in question cannot support himself (or herself) as a result of physical or mental disability and that they are chiefly dependent upon the plan member for support.
If you are employed by an employer with at least 50 employees then you are permitted to take a leave of absence without loss of health insurance for up to 12 weeks in certain circumstances. This protection is guaranteed by the Family and Medical Leave Act (FMLA) to cover things like the birth of a child, sickness or the need to care for a seriously ill family member.
Federal law allows states down to local government level to exempt government employees from some areas of coverage in self-insured group plans and many Forida's public employers take advantage of this to a degree. As exemptions vary widely from one employer to the next it is a good idea to find out the exact coverage provided if you are a public employee. This information may also be found by contacting The Center for Medicare and Medicaid Services (CMS) which maintains a list of employer exemptions.
Though under Florida law you may not be refused membership of a group health plan on the basis of health, there are various circumstances in which plans are allowed to impose exclusion periods for pre-existing conditions. This is however a complicated topic and one that is therefore the subject of a further article.
It may be a simple mistake - but it's also possible that your insurance plan has coverage gaps that you didn't know about before.
One of the following simple problems may be solved with one phone call:
1. Your insurance company may have made a payment to the physician, but their billing department hasn't posted it yet. Your bill and the check just got crossed in the mail.
2. You gave your insurance information to the receptionist when you signed in, but she didn't give it to the physician's billing office. The doctors and hospitals are separate businesses, and they don't always share information. The provider's phone number is on your bill - give them a quick call to straighten it out.
And then there's the hard answer:
3. You really owe the money. And yes, you have to pay it. If you don't, you will very likely be sent to a collection agency.
The following is a true story. I've left out any details that might violate this family's privacy, but I assure you that I am not making any of this up.
A young father whose child had an accident in the home needed immediate surgery. The parents took the child to a hospital that was participating with the family's insurance company.
However, the emergency room surgeon was not participating with any insurance company.
It is extremely common for ER physicians to choose not to participate with insurance. After all, the only reason that doctors contract with insurance companies is to increase their business from insured patients - but the insurance companies limit their fees. If the doctor needs the business, the lower fees may be worth it.
But ER physicians and other specialists don't need to drum up business - they usually have more patients than they can handle.
Like many ER's in our city, this particular emergency room has no physicians at all on staff who participate with insurance companies.
This family thought they were covered because they made an effort to get their child to the right hospital, but they didn't know that the hospital and the physicians (and the people who read the x-rays, and the anesthesiologists, etc.) are separate businesses who may (or may not) have contracts with the insurance company.
In other words, they didn't know they were underinsured.
Let's see how this affected this family:
The total surgery bill for this child was over $9,000.00. If the sugeon had been participating, the family would have owed the surgeon less than $34.00. That is not a typo. His insurance plan paid 99% of the amount it would have paid a contracted surgeon. Most plans actually pay a much lower percentage - this family had an unusually good plan through their union.
A non-participating provider does not have to accept what the insurance pays, and this surgeon charged over $6,000.00 more than the insurance company considered a "usual and customary fee." So the family paid the difference.
If you get an unexpectedly high bill from a health care provider, be sure to call the insurance company to see if you can get it straightened out. It may have been a simple mistake. But if your bill came about because of a scenerio similar to the one described above, it won't matter how nice your insurance company's customer service specialist may be. There's nothing she can do for you.
The insurance company can't force an independent business to charge you the amount other providers accept for the same service.
But this family is actually lucky. If their family were not insured at all, the ER room and surgical fees would have left them owing over $20,000.00, almost three times what an insurance company would pay for the same services.
If you're insured in America, you're underinsured.
How can you tell if this could happen to you? Get out your benefit booklet and go to the emergency or urgent care section. If you see the words "non-participating providers paid x% of billed charges," you don't have a problem. If, however, you see the words "non-participating providers are paid x% of the amount we would pay a contracted provider," the scenario above could happen to you.
Then go to the benefit summary, which is probably near the front of your benefit booklet. If you have a plan that has different benefits for "preferred" and "non-preferred" providers, you'll need to use the lower benefit to see what portion of the bill your insurance company will pay.
Make sure you go to a participating emergency room if you can (emergencies don't always happen near a convenient participating hospital, of course), and then be prepared for higher fees from those physicans and technicians who don't participate with your plan.
To see why uninsured patients pay so much more for their health care, read the rest of the article at the web address shown below.
Both Donald Saunders & Jonni L Good are contributors for EditorialToday. The above articles have been edited for relevancy and timeliness. All write-ups, reviews, tips and guides published by EditorialToday.com and its partners or affiliates are for informational purposes only. They should not be used for any legal or any other type of advice. We do not endorse any author, contributor, writer or article posted by our team.