1. What if I am out of town and need to go to the emergency room?
   
   If a medical emergency should arise while you are out of town,go to the emergency room and it will be covered as an in-network benefit.
   
   
2. How long can my child be covered under my plan if they are mentally or physically handicapped?
   
   Coverage your child may continue as long as he or she is dependent upon you for maintenance and support. Some insurance companies require the insured to complete a Proof of Disability form.
   
   
3. Can I cover my child if he/she is in college?
   
   Yes, as long as he/she falls within the age requirements set by your carrier. You will also need to provide documentation that they are a full time student. Some insurance companies require documentation each quarter/semester. Most policies have an age limit for dependent coverage. Please refer to your certificate of coverage for details.
   
   
4. My new insurance company asked for a Certificate of Credible Coverage. Why do they need this and where do I get one?
   
   Credible Coverage helps to reduce the amount of time you must wait to have pre-existing conditions covered.
   
   The Certificate of Credible Coverage states the period you were covered under your previous health plan. Your new insurance company requests this form to help determine the amount of time you will wait before pre-existing conditions are covered. The time you were covered by your previous policy may be deducted from the new policy's waiting period. You can obtain this certificate by calling and requesting it from your previous insurance company.
   
   
5. My insurance company declined charges over UCR. Do I have to pay those charges?
   
   If you used an in-network provider, you are not liable for the amount above UCR. If you use out-of-network providers or benefits, you may be required for changes above the UCR.
   
   
6. If I am injured while at work, does my health insurance cover the injury?
   
   Your company's Worker's Compensation should cover injuries that take place while you are on the job. Your health insurance company may not be responsible for covering injuries that are work related.
   
   
7. As a new employee, how long must I wait to be eligible for my employer's health insurance benefits?
   
   Your employer's policy decides when to begin coverage start for new hires. Coverage may begin as early as the date of hire to a maximum of 90 days. Please ask your employer for details on your probationary period.
   
   
8. When can I add my spouse or dependents to my policy?
   
   In order to add a dependent to your existing policy a qualifying event must occur.
   
   
9. I own a small business and have full-time and part-time employees and plan on offering health insurance. How do I determine who is eligible for coverage?
   
   For companies with 2-50 employees, federal law (HIPAA) requires you to provide coverage for all employees who work an average of 25 hours or more per week. Companies with over 50 employees can determine their own guidelines for eligibility.
   
   
10. What happens if I need to go to the doctor or have a prescription filled but have not received my ID card?
    
    You will need to pay for the office visit or prescription, and then submit a claim to be reimbursed for your expense. Some insurance companies have websites that allow you to verify coverage. Most doctors will accept a printed copy of this page in the absence of an ID card.
    
    
11. My insurance premiums increased dramatically at renewal. What are my options?
    
    Insurance companies are required to mail renewals at least 30 days before the renewal date. There are several options available:
    • Review different benefit options with your current health insurance company
    • Compare your current premium and benefits with that of another insurance company.
    • Requalify your company with your current insurance company.
    • Ask a GBA representative for more information. 
      
      
12. Are there health insurance options for my part-time employees?
    
    Yes. Part-time employees who are not eligible for the group plan may elect individual coverage. Ohio law does not allow the employer to pay for or reimburse the cost of individual insurance. The employer may however, deduct the premiums pretax from the employee's pay check.
    
    
13. Can I be denied individual coverage?
    
    Yes. Individual health policies are not guaranteed issue.
    
    
14. Can an insurance company cancel my individual policy?
    
    With few exceptions, insurance companies must renew your individual health insurance coverage, if you want it renewed. This means that your coverage CANNOT be cancelled because of your medical condition or insurance claims you've submitted in the past.
    
    An insurance carrier may cancel your coverage ONLY for the following reasons:
    
    
    • You do not pay your premiums; you make late payments, commit fraud, or lie to your insurance company
      
    • Your insurance company is no longer offering your particular type of coverage
      
    • You have coverage with a managed care organization, such as an HMO, and you move outside of the service area
      
    • You qualified for coverage as a member of a bona fide association, and your membership in the association ends.
    
    (From HIPAA Online http://www.hcfa.gov/medicaid/hipaabout_us/online/ 4/23/02)
    
    
15. How are benefits paid if I am also covered by my spouse's health insurance plan?
    
    If you have a group plan which does not coordinate benefits, it will always be primary.
    Otherwise, Coordination of Benefits of benefits would be applied to your claims. When an employee has a medical claim, their employer's health plan is considered the primary plan. The spouse's plan would be secondary and cover part or all of the remaining cost. When coordinating benefits, the total payment from both plans cannot exceed the UCR amount. Please refer to your Certificate of Coverage for details on your plan.
    
    
16. What if my spouse and I both have insurance covering our children?
    
    If you have a group plan which does not coordinate benefits, it will always be primary parent. When both parents are covering their children on separate health plans the birthday rule usually applies. When coordinating benefits, the total payment from both plans cannot exceed the amount of the treatment. Please refer to your Certificate of Coverage for details on your plan.
    
    
17. My insurance company declined my emergency room visit stating that is was "not" a medical emergency. What does this mean and how can I get the claim paid?
    
    A "medical emergency" is a condition of such strong pain and severe symptoms that the lack of attention could jeopardize life, or limb. If your visit was a true medical emergency, you can appeal to your insurance company by sending them the complete emergency room report from the hospital. The appeal process is documented in your Certificate of Coverage.
    
    
18. Why is my urgent care copay less than my emergency room copay? How do I know where to go?
    
    Urgent Care Facilities charge substantially less than an Emergency Room. You would go to an Urgent Care facility if you have an unforeseen condition that requires medical attention without delay but does not pose a threat to life or limb.
    
    
19. What is the difference between brand name and generic prescriptions?
    
    Brand name drugs are the original medications developed to treat an illness. Generic medications are equivalent to the brand name drug, but distributed by a different company after the patent on the brand name drug has expired. The generic prescription may look different but the active ingredients are the same as the brand name and should have the same effects. Check with your physician to see if an alternative is available.
    
    
20. Is my newborn automatically covered by my insurance plan?
    
    No. You must submit an enrollment/change form to your insurance company within 31 days of birth. This also applies to foster and adopted children.
    
    
21. When I get married, how do I add my spouse?
    
    You must submit an enrollment/change form adding your spouse. Most insurance companies require you add your spouse within 31 days from the date of marriage.
    
    
22. My daughter is pregnant and covered on my group insurance plan. What does my insurance cover?
    
    In most cases, your daughter and the birth would be covered under your insurance plan. However, your grandchild would not be covered. Please refer to your Certificate of Coverage for details on your plan.
    
    
23. How can my grandchild receive coverage under my plan?
    
    You must provide proof of legal custody to your insurance company. This policy also applies to coverage to adopted and foster children.
    
    
24. Do I have to cover my child if I am divorced?
    
    The primary plan is usually determined by the divorce decree. If the divorce decree gives joint custody and does not mention health care, in most cases, the birthday rule applies. If the decree does not state who is responsible for the child's health care, the plan of the parent with legal custody is primary.
    
    
25. Do I have to call my insurance company prior to tests that are recommended by my doctor?
    
    Many procedures require pre-certification. It is recommended you call your insurance company and primary physician before tests are performed at an out patient clinic or hospital. If your insurance company denies these tests you may file an appeal. Please refer to your Certificate of Coverage for details.
    
    
26. If I go to a network hospital but see a doctor that is not in my network am I liable for those charges?
    
    The non -network physicians may balance bill after your insurance company pays the UCR amount.
    
    
27. Are mammograms covered under my plan?
    
    Yes. The State of Ohio mandates a minimum of $85 be allowed for coverage of mammograms. However, before your insurance company pays the $85, you may have to satisfy your co-payments or deductibles.
    
    
28. When my doctor is not available I see another doctor in the same office. My insurance company denies the claim because the doctor I saw is not my Primary Care Physician. How do I get my claim paid?
    
    Every doctor has a tax ID number they use to file claims. If your PCP's tax ID number is not on your claim, it can be denied. You need to contact your doctor's office and ask them to resubmit the claim with the correct tax ID number. Sometimes by contacting your insurance company and explaining the situation, they will adjust the claim after verifying that your doctor is part of a large practice.

Need More Help? Contact a GBA Insurance Professional.