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Health Insurance

Health insurance policy defined

Health insurance policy defined

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Health insurance is designed to protect you from the financial risks associated with illness and disability by offering a way to reduce medical costs to more reasonable amounts. 

Health insurance and how it works.

Health insurance is most commonly sold under group benefits. Most health insurance plans will require that you pay some of the costs of covered medical services, which is called cost-sharing. It will vary between different types of health plans, but most will include a deductible, copayment and out-of-pocket-maximum. More specifically:

  • Health insurance provides coverage for various medical needs, such as physician and nursing services, hospital services, supplies, and equipment. These benefits are subject to cost-sharing limits, such as deductibles, coinsurance, copay and maximum caps, to encourage policyholders to use these services reasonably.
  • What you pay after receiving a medical service will count towards your annual deductible first. When you reach that amount, you may pay copay or coinsurance, which you will continue to pay until you reach your out-of-pocket max.
  • Cost-sharing refers to how health care costs are shared between the insurance company and you. It’s important to understand how the cost-sharing structure works as it can have a big impact on the medical costs you need to pay. 

What to Lookout For in a Health Insurance Plan

In addition to regular premium payments, visits to a medical facility will result in out-of-pocket expenses you will need to cover. These are deductibles, coinsurance and copay. 

A deductible is the set amount that you must pay before your insurance company starts covering your medical bills.

For example, if your health plan has a $2,000 deductible and your medical bill totals $5,000, you will need to cover $2000 and your insurance company will pay the remaining $3000 of your medical bills. If you have already paid $2000 in medical bills that year, you will only pay an amount equal to coinsurance or copay while your insurance will pick up the difference

Your deductible will also determine what your insurance premium is – or your monthly insurance costs. By tweaking around the deductible when choosing a policy, you can manage your insurance cost. While it’s convenient to have a lower deductible, they usually come with higher premiums. You can lower your insurance costs by choosing a policy with a higher deductible and self-insuring instead. Finding the optimal balance between a deductible and premium to fit your personal preference and financial circumstances is essential.

After you’ve reached your deductible level, you will start paying coinsurance for some types of healthcare service, usually less routine ones such as hospitalization or some medical treatments.  Coinsurance is a percentage of medical expenses you will pay for each of these medical services after you’ve paid your deductible and until you meet your out-of-pocket maximum for the year. For example, if you have a plan with a 20% coinsurance, you will pay 20% of a medical bill, while your health insurance will cover the remaining 80%. Your out-of-pocket maximum for the year is the maximum dollar amount you can pay in any given year. This means that you will continue to pay the coinsurance until you reach this amount of expenses.

Some medical services, usually routine ones such as doctor visits or prescriptions, will be subject to a copay instead of coinsurance. Copay is a fixed amount you need to pay for each of these covered medical services regardless of your deductible. The insurance company covers the remaining amount. What you pay in a copay may or may not count toward your deductible, so make sure you check that before you receive a medical service. For example, if you have a $20 copay for a visit to the doctor’s office, you must pay this amount at each visit, in most cases even if you already met your deductible.

A limit is a cap on the benefits the insurance company will pay, which can be annual or lifetime. However, under the current law, lifetime and annual limits on all essential health services are prohibited as well as many services that may not be considered essential. For some non-essential services, your insurance may express an annual limit as a dollar amount of covered services or as the number of medical visits covered. Once you reach the annual limit, you must pay all health care costs for the rest of the year. Lifetime maximum refers to the maximum dollar amount that your insurance company will pay you for healthcare services during your life. Annual and lifetime limits do not apply to essential health services.

Why Vero is right for you

You pay lots of money on health insurance, but how do you really know whether these coverage levels make sense? 

Let’s make sure the insurance you have is the protection you need. 

Do you have the protection you need?

Life is full of risks. To your family. Your assets. Your future. The problem is traditional solutions that propose traditional answers, one policy at a time.

Vero’s fast and free Protection Plan is an unbiased analysis of all your risks. We’ll recommend what insurance to buy — and which policies you can safely cancel to save money.

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©2020 Vero Intelligence, Inc.
370 Convention Way
Redwood City, CA 94063

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Health Insurance

Medical claims and next steps

Medical claims and next steps

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Dealing with a medical situation, especially if it’s an emergency, can be a stressful time for anyone, and filing a claim can add to the stress and anxiety. To help you navigate the required procedures, including tips on what to do if your claim has been denied, we created a simple guide to walk you through the health insurance claim process.

What happens after you receive a medical care

There are two ways, health insurance claims are handled, after you visit the doctor: either your doctor sends the bill to your insurance or you fill in the claim form and send in the paperwork yourself.

  • The first option where the doctor sends the bill to the insurance happens if you received medical service from an in-network provider. Then the medical provider will do all the work for you.
  • The second option, filling in the claim form and sending in the paperwork yourself, usually happens when your health service provider is not in the network of your insurance company. In this case, your doctor will give you an itemized bill that lists all services and medications that you received and the costs associated with each of them. You attach this list to your claim form that you get from your insurance company. If you need help with filling in the form or have doubts, make sure you contact the insurance to clarify them. That way, you make sure your claim won’t be rejected for some administrative reasons like incorrect data.

What happens after your claim is filed

When your insurance company receives the claim, a claim processor will deal with processing the expense of your medical care. This includes reviewing your claim for completeness and accuracy and also checking whether the services you received are covered under your policy. If the services are covered, the claim processor will also check your copay, deductible and out of pocket maximum.

After this, you will receive an Explanation of Benefits (EOB), a letter from your insurance explaining facts about the claim, stating what they will pay and what the patient needs to pay. The EOB may look similar to a bill but is not a bill. You want to make sure that all the details in your EOB are correct, including names, date of service, charges and member responsibility (copay, deductible and coinsurance).

Your medical service provider will send you the final bill. Compare it to the EOB and if there is any remaining balance, make sure to pay it as soon as possible. If you need to pay the additional money after the insurance company has covered its part, the medical service provider will send a separate bill.

Reasons for a claim to be denied

Most claims processes are simple, but sometimes a claim might be rejected.  Claims can be denied for various reasons, some more difficult than others.

For example, administrative errors may cause rejection. This may not be an enjoyable experience, but it’s a better option as it’s relatively easy to fix.

On the other hand, a claim may be rejected because your policy doesn’t cover the medical service or medication you received, or because the insurance company doesn’t see the medical necessity for the procedure. Make sure you call your insurance to check the reasons behind the claim rejection.

If medical necessity is the reason for denial, but you really need the medical service, you can work with your doctor to provide evidence to the insurance company that you do need the requested medical assistance. 

Sometimes the insurance company will not approve your expensive procedures before you try less costly options. This is called step therapy or “fail first”.

Your healthcare plan may give you the coverage only for medical assistance offered by providers that are part of your plan’s provider network. You may try to convince your insurer that the provider you selected is the only one capable of providing the service, but be aware that you may pay an additional amount in the case that an out-of-network provider is approved.

How to avoid claim denial

The best way to ensure that your claim gets accepted is to do the following:

  • Contact your insurer before scheduling a medical service.
  • Check all the rules about the pre-authorization process, provider network, step therapy and any other aspects that may affect the outcome of your claim process.

Filing claims appropriately is the safest route to avoid a claim denial. Also, try to use the medical care providers (hospitals, doctors, pharmacies, and other services) that are part of your plan’s network of providers. In this case, not only will you minimize the odds of your claim being denied, but your provider will also file the claim for you. If you go out of network, you will have to file the claim yourself.

What are my options if my claim gets denied?

If your claim gets denied, you can always file an appeal. Affordable Care Act gives consumers the right to challenge health claim denials. The Affordable Care Act requires insurers to send instructions about how consumers can initiate an appeal process every time they deny a claim.

A study conducted by the Kaiser Family Foundation shows that, on average, 18% of in-network claims of healthcare.gov issuers were denied in 2017. However, only 0.5% of these are appealed. This is a lost opportunity, as many of these denials end up being reversed. Whatever the reason for rejection, you should not take it as final.

There are four types of appeals.

  • Pre-service (or pre-authorization) appeal. You can submit this type of appeal when your plan has denied your request to receive medical services before you were given the prescribed care. The insurers have 30 days to respond to this type of appeal. 
  • A post-service appeal. You submit it when your health plan has denied a claim for reimbursement or payment of a medical procedure. The insurers have 60 days to respond to this type of appeal.
  • Urgent care (or expedited) appeal. You can request an urgent appeal if you are currently receiving or you were prescribed to receive treatment and your medical provider believes a treatment delay could jeopardize your life or health. Insurers are required to make the decision within 72 hours after receiving the appeal.
  • Marketplace plan appeal. The Affordable Care Act gives consumers the right to appeal a decision made by a state or federal health insurance exchange and the decision must be made within 90 days.

There are usually two levels of appeals both for pre-service and post-service denials. One is internal and is conducted within your insurance company. The second is external when an independent third party reviews your claim. External appeal procedures will differ from state to state as they are governed by state regulation. Don’t underestimate the power of external appeal.

Tips for increasing the odds of appeal approval

  • You will need to submit a letter of support and notes from your doctor indicating the medical reasons for the requested service, as well as any relevant medical literature and peer-reviewed articles documenting the effectiveness of the requested services. 
  • You may also want to write your own letter to explain in your own words the medical condition that you want to treat and how it impacts your life. 
  • You can submit both letters at the same time. Insurance companies are required by regulation to respond to a written appeal, so you will probably receive a response within the next 7-10 days. If that is not the case, contact your insurance company to make sure your appeal was received.

You pay lots of money on health insurance, but how do you really know whether these coverage levels make sense? Let’s make sure you’re protected.

Do you have the protection you need?

Life is full of risks. To your family. Your assets. Your future. The problem is traditional solutions that propose traditional answers, one policy at a time.

Vero’s fast and free Protection Plan is an unbiased analysis of all your risks. We’ll recommend what insurance to buy — and which policies you can safely cancel to save money.

Continue reading

©2020 Vero Intelligence, Inc.
370 Convention Way
Redwood City, CA 94063

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Health Insurance Vero News

Health insurance and COVID-19

Health insurance and COVID-19: what should I know?

Vero is committed to helping individuals with their health
and well-being during this unprecedented global pandemic.
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Does my plan cover testing and treatment related to COVID-19?

Many of the major carriers are including coverage for testing and treatment related to COVID-19. While each carrier and plan can differ in terms of what that entails, it’s best to check with your carrier directly on what is available to you. Due to high volume, please anticipate longer wait times when calling an insurance company and utilize the other contact methods such as email, chat and accessing some of the other resources through your user account at that carrier’s website (if you don’t have an account and you’re a member of that carrier, sign up now). America’s Health Insurance Plans (AHIP) has posted a great resource here.

Learn how each state is working to promote relief and flexibility to insurance companies.

What happens to my health insurance and dependents if I am furloughed or laid off?

Quickly access or retrieve information from your employer’s HR and benefits department to fully understand what will happen and where you can find more information. Every company can be different in this regard. If you find yourself without coverage, or soon-to-be without coverage, you can search for plans on the state or federal exchanges (depending on your state) or, if you have a spouse or partner who has an employer sponsored plan, you may be able to enroll in that plan. The key is to search and enroll as soon as you know when your coverage will lapse or cancel so that you are not uncovered during any transitions. 

If your company offers you COBRA or another type of continuation of coverage (i.e. “mini-COBRA), it’s best to read the literature thoroughly and respond accordingly within the time frames provided. If you haven’t been provided any language or have questions, reach out to your employer’s HR or benefits department. For more information on COBRA, see here.

Can I change plans or get new coverage in the middle of the year due to the uncertainty of the COVID-19 pandemic?

Typically, with most plans you are not allowed to change without a qualifying event such as an involuntary loss of coverage, life event (marriage, new baby), etc.  The best way to find out is to contact your insurance company directly, or if you receive coverage from an employer sponsored plan, reach out to the HR and benefits department and/or log into any HR or benefits software available to you to find out more. Some states and insurance companies may offer relaxed guidelines and flexibility on many of these standard rules given the pandemic. Please contact the insurance companies directly to find out what’s available.

COVID-19 and managing stress: How can I access mental health and well being outlets/care and know what’s covered?

Locate and upload to Vero your health insurance plan summary or Summary of Benefits and Coverage (SBC) which you can find in your insurance company’s online portal or your hr/benefits portal through your company. Vero will reach out with recommendations and support.

Contact your employer, HR/benefits department, or your insurance carrier directly to find out what is available and how to access mental health care. There are many mental health-related coverages included in your current health and life insurance plans. See here for some of the ways insurance carriers are providing access to mental health resources. Review the covered mental health benefits in your health plan, as well as the employee assistance plans (EAP) available through your employer or insurance carrier. For information about mental health coverage, see this article by the American Psychological Association.

I’m uninsured and worried about getting sick with COVID-19. What can I do to obtain health insurance?

Some states have added special enrollment periods allowing the ability to sign up for health insurance later than usual. Otherwise you can access Healthcare.gov to see what might be available. If you’re employed and eligible for health insurance, reach out to your HR and benefits department.

What is “Telehealth?” How do I know if I have it? Should I use it, how and when? Where do I find it? Same for “VirtualCare”

Telehealth involves the delivery of healthcare services via telecommunications and virtual technology. With the onset of COVID-19, we have seen a natural boom in telehealth, due to the stay-at-home orders and the unprecedented amount of pressure on frontline healthcare workers. Overnight, it has gone from a convenience to the sole way to access healthcare less an emergency. See here for a great resource on telemedicine.

With Vero, let’s make sure you’re protected and making highly informed decisions.

Make sure the protection you have is the protection you need!

Life is full of risks. To your family. Your assets. Your future. The problem is traditional solutions propose traditional answers. Life insurance. Home insurance

Continue reading

©2020 Vero Intelligence, Inc.
370 Convention Way
Redwood City, CA 94063

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