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Most indemnity policies
allow you to choose any doctor and
hospital that you wish when seeking
medical care services. The hallmark
of traditional fee-for-service
insurance is choice. You are given
the choice of what provider to visit
when seeking covered medical
services with few if any geographic
limitations. When purchasing an
indemnity policy, you may often have
a deductible. The deductible is the
amount you are required to pay
before policy benefits are provided.
You may have a choice in the amount
of your deductible. If your medical
care charges are covered, or
eligible for payment under the
policy, any applicable deductible
will apply. Once the deductible has
been paid, the remaining charges are
reimbursed to you at a specified
percentage according to the policy
contract. The difference between
eligible charges and the percentage
paid is called a "copayment," and is
normally your responsibility. The
policy or an employee benefit
booklet (if your indemnity policy is
group coverage) will spell out the
terms and conditions of what is
covered and what is not covered.
Read your policy or benefit booklet
before you need medical care services
and ask your medical insurance agent,
insurance company, or employer to
explain anything that is unclear.
The California Department of
Insurance (CDI) regulates indemnity
policies. If you have an individual
or
group medical insurance policy
that is a traditional
fee-for-service policy issued by a CDI
licensed medical insurance
company, then you can contact the CDI for assistance. Since
jurisdiction is divided between
several state and federal agencies,
it can be confusing to determine who
regulates your medical care coverage.
The CDI is always available to
assist consumers with medical care
questions or to direct consumers to
the correct agency for assistance.
Please see the last page of this
brochure for the many ways you can
contact the CDI.
Important Points to Remember
About Indemnity Policies:
-
You have the freedom to choose
your doctor, specialist, or
hospital with few if any
limitations.
-
Your options are seldom if ever
limited by geographic
restrictions.
-
You may be responsible for
paying a deductible before
covered medical benefits are
reimbursable.
-
You may be required to pay a
co-payment for covered medical
services.
-
You can seek assistance from the
CDI for questions regarding any
indemnity policy.
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A Preferred Provider
Organization (PPO) provides a list
of contracted "preferred" providers
from which to choose. You receive
the highest monetary benefit when
you limit your medical care services
to those providers on the list. If
you go to a doctor or hospital that
is not on the preferred provider
list referred to as going
"out-of-network", then the plan
covers a smaller percentage of your
medical care expenses or may cover
none of your medical care expenses
based on the contract wording of the
plan. Always check with your PPO or
consult your list of preferred
providers before you seek medical
care services to make certain your
physician or hospital is a
contracting provider (part of the
network). Make sure that your doctor
refers you to medical care providers
within your PPO network, if
applicable.
PPOs in
California can be regulated by
either the CDI or the Department of
Managed Medical Care (DMHC) depending
on whether the underwriting company
(the company backing the policy) is
a licensed insurance company or a
managed care company. The DMHC has
sole jurisdiction over
Blue
Cross/Blue Shield PPO medical plans.
If you are confused about whom to
call regarding a PPO problem or
concern, then consult your plan
documents for regulatory
information. If there is still some
question, then you can reach the CDI
or the DMHC for assistance at the
contact information given in the "Resources"
section of this brochure.
Important Points to Remember
About Preferred Provider
Organizations:
-
You receive the highest monetary
benefit when staying within the
PPO network.
-
You may have the option to go
outside the PPO network at a
higher monetary cost to you.
-
You should consider checking if
your doctor or any specialist
referred to you is part of the
PPO network before utilizing
covered services.
-
You can seek the assistance of
the DMHC on all Blue Cross/Blue
Shield PPO medical plans.
-
You can contact either the CDI
or the DMHC for clarification
regarding PPO issues.
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Membership in a Health Maintenance
Organization (HMO) requires plan
members to obtain their medical care
services from doctors and hospitals
affiliated with the HMO. It is
common practice in HMOs for the plan
member to choose a primary care
physician who treats and directs
medical care decisions and who
coordinates referrals to specialties
within the HMO network. The doctors
and hospital personnel may be
employees of the HMO or contracted
providers. Since HMOs operate in
restricted geographic regions, this
may limit coverage for plan members
if medical treatment is obtained
outside the HMO network or coverage
area.
California HMOs are required
to cover
medically necessary
emergency services even when outside
of their coverage area. The intent
of managed care products is to
create less costly delivery of
medical care services while
maintaining quality medical care by
specifying provider choice. HMOs
offer access to a comprehensive
package of covered medical care
services in return for a prepaid
monthly amount (premium). Most HMOs
charge a small copayment depending
upon the type of service provided.
All
HMOs in California are regulated
by the Department of Managed Medical
Care (DMHC). If you have a complaint
with an HMO, contact the member
services department of your HMO.
HMOs are required to have an
internal complaint/grievance process
in place. If you file a grievance
and it has not been resolved within
30 days or there is some question as
to the HMOs decision, then you may
contact the DMHC for assistance.
Please see contact information
listed for the DMHC in the
"Resources" section of this
brochure.
Important Points to
Remember About Health Maintenance
Organizations:
-
You must obtain medical care
services from HMO providers,
except in certain emergency
situations.
-
Your choice of primary care
physician is important because
he/she directs your care. Also,
your primary care physician
often coordinates referrals to
specialties within the HMO.
-
Your options may be limited by
the geographic restrictions of
the HMO network.
-
You may be charged a small
copayment each time you utilize
an HMO covered service.
-
You can seek assistance from the
DMHC on all HMO and managed care
questions.
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Self-Insured Medical
Plans have gained in popularity
among large employers and many labor
unions as well as school districts
and other municipalities. These
groups provide a pool of money and
then proceed to pay for the medical
care services of their members
(employees) from this pool. It is
common for self-insured plans to
turn over the administration of
their medical plans to a Third Party
Administrator (TPA). The TPA handles
all administrative tasks including
claims processing and payments.
Often the employer can contract with
an insurance company to act as a TPA
for all medical care claims.
Most
self-insured medical plans fall
under the Employee Retirement Income
Security Act (ERISA). ERISA is
federal law that is enforced by the
U.S. Department of Labor, Employee
Benefits Security Administration (DOL-EBSA).
If you are a member of a
self-insured medical plan through
your employer security or union,
then you can contact the DOL-EBSA
for assistance. However, the
DOL-EBSA does not regulate
self-insured medical plans that are
sponsored through school districts,
other municipalities, and churches.
If you are a member of this type of
plan, you can file a complaint with
the plan directly or you may seek a
legal remedy through a court of law.
The DOL-EBSA is available to answer
questions about self-insured
employer plans that come under ERISA
regulation. You can gain information
on the type of plan that you
participate in by contacting your
employer or union. If there is still
some question, then you can contact
the DOL-EBSA for clarification.
Please see the "Resources" section
of this brochure.
Important Points to Remember
About Self-Insured Medical Plans:
-
If you work for a large
employer, have a union
affiliation, work for a school
district, or work for a
municipality, the medical plan
offered to you may be a
self-insured entity.
-
An insurance company or a TPA
may administrate a self-insured
medical plan.
-
Self-Insured medical plans are
most likely subject to federal
ERISA law.
-
If your self-insured medical plan
is not a school district,
other municipality, or a church,
you can seek help from the
DOL-EBSA.
-
If your
self-insured medical plan
is a school district, other
municipality, or a church, you
may seek assistance from the
plan directly or from the
courts.
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MEWAs permit
employer members of trade, industry,
professional, and other associations
to create trust funds for the
purpose of offering and providing
medical care benefits to their
employees. Currently, fewer than ten
MEWAs have been issued certificates
of compliance by the CDI, which
permit them to operate legally in
California. Because of significant
and widely publicized mishandling in
the 1980s and early 1990s,
legislation was passed to cleanup
problems with MEWAs. This
legislation forced all MEWAs to file
applications for certificates of
compliance by November 30, 1995, or
cease operating in California. Only
MEWAs that satisfied strict
requirements were granted
certificates of compliance. It is
now illegal for new MEWAs to form
and to offer medical care benefits.
If your employer presents a medical
plan to you involving a new
MEWA, then contact the CDI
immediately. If you receive your
medical care benefits through one of
the approved MEWAs, then you can
seek assistance from the CDI if you
have any questions or complaints.
Please see the last page of this
brochure for complete CDI contact
information.
Important Points to
Remember About Multiple Employer
Welfare Arrangements:
-
Your employer may offer a MEWA
medical plan if they are an
employer member of a trade,
industry, professional, or other
association.
-
There are currently less than
ten MEWAs operating with CDI
certificates of compliance.
-
After November 30, 1995, no new
MEWAs can form, operate, or
apply for CDI certificates of
compliance.
-
You can contact the CDI for any
questions regarding MEWAs.
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California medical insurance coverage is
marketed to consumers through
individual policies or group
policies.
Individual medical
insurance coverage should be pursued
when your employer does not offer
medical insurance as a benefit of
employment, when you cannot be named
as the dependent on another persons
insurance policy, or when you are
not a member of a professional or
trade association that offers group
coverage. Many consumers are
self-employed, contract employees,
or work for small employers and do
not have access to a group policy
secured by an employer. Individual
coverage can be obtained by
contacting a
licensed medical
insurance agent or broker. You will
need to
complete an application that
includes your medical history, which
will be reviewed by a
medical
underwriter at the medical insurance
company. If you meet the
underwriting qualifications and are
issued a policy, the company may not
cover preexisting conditions up to
one year after the effective date of
the policy. However, if you have
been previously insured under an
individual or group policy without a
break in coverage of more than 62
days, your new insurance company
must apply the prior creditable
coverage (refer to the "Medical
Insurance Terms") towards
any waiting period for preexisting
conditions.
Individual medical
insurance companies may reject your
application based on your medical
history.
Group medical insurance offers
certain advantages over
individual
medical insurance policies. The
waiting period for preexisting
conditions is six months, not one
year as with individual policies.
Also, if you have been previously
insured under a group policy without
a break in coverage of more than 180
days, your new insurance company
must apply the prior creditable
coverage toward the six-month
waiting period for preexisting
conditions. Large employer group
medical insurance (more than 50
employees) and association group
medical insurance, like individual
medical insurance, is subject to
medical underwriting. You can be
denied coverage based on your
medical history. Medical
underwriting rules for small
group
medical insurance (2-50 employees)
differs from large group and
individual medical insurance
policies. Regardless of any
preexisting condition, you must be
offered coverage under a small group
policy on a guaranteed issue basis.
However, the small group insurance
company can utilize the six-month
waiting period for preexisting
conditions. Of course, if you have
prior creditable coverage it must be
applied to decrease or eliminate the
waiting period.
Important Points to Remember
About Individual and Group Medical
Insurance Coverage:
-
Medical insurance coverage is
marketed to consumers under
either individual or group
policies.
-
Individual and large group
policies are subject to medical
underwriting.
-
Qualifying creditable coverage
must be applied towards the year
waiting period for preexisting
conditions in individual
policies and towards the
six-month waiting period for
preexisting conditions in group
policies.
-
Small group policies require
that coverage be offered on a
guaranteed issue basis
regardless of any preexisting
condition.
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The Consolidated Omnibus Budget
Reconciliation Act (COBRA) is
federal law that extends your
current
group medical insurance when
you experience a qualifying event
such as termination of employment or
reduction of hours to part-time
status. The extension period is 18
months and some people with special
qualifying events may be eligible
for a longer extension. To be
eligible for COBRA, your group
policy must be in force with 20 or
more employees covered on more than
50 percent of its typical business
days in the previous calendar year.
Indemnity policies, PPOs, HMOs, and
self-insured plans are all eligible
for COBRA extension; however,
federal government employee plans
and church plans are exempt from
COBRA. Individual medical insurance
is also exempt from COBRA extension,
which may be another reason to
pursue participation in group medical
plans, if possible.
Cal-COBRA is California law that has
similar provisions to federal COBRA.
With Cal-COBRA the group policy must
be in force with 2-19 employees
covered on at least 50 percent of
its working days during
-
the preceding calendar year, or,
-
the preceding calendar quarter,
if the employer was not in
business during any part of the
preceding calendar year.
Eligibility for Cal-COBRA extends to
indemnity policies, PPOs, and HMOs
only. Self-insured plans are not
eligible. Unlike COBRA, church plans
are eligible under Cal-COBRA. It is
important to note that both COBRA
and Cal-COBRA do not apply to
individual medical insurance.
As of January 1, 2003, the extension
period for Cal-COBRA has been
changed from 18 months to 36 months.
If you become eligible for Cal-COBRA
after January 1, 2003, you will have
the benefit of Cal-COBRA coverage
for a full 36 months instead of the
prior 18-month coverage extension.
California Insurance Code (CIC)
Section 10128.59 provides a similar
extension under Cal-COBRA for those
who have exhausted their 18 months
on federal COBRA (or longer in
special circumstances) for a total
extension that cannot exceed 36
months. For the special Cal-COBRA
extension to apply, you must have
become eligible for COBRA after
January 1, 2003, and the employer's
master policy must be issued in
California. If the group master
policy is not issued in California,
then the employer must employ 51% or
more of its employees in California
and have its principal place of
business in California for their
California employees to take
advantage of Cal-COBRA.
COBRA is regulated by the DOL-EBSA,
and Cal-COBRA is jointly regulated
by the CDI and the DMHC depending
upon what type of group coverage you
have (indemnity or HMO). These
agencies can provide further
information on the time frames
employers and insurance
companies/medical plans must follow
to offer COBRA or Cal-COBRA
extension coverage for eligible
employees and their dependents.
Also, information can be furnished
on the actions and responsibilities
required by employees to participate
and elect continuation of benefits
under COBRA or Cal-COBRA. When
experiencing questions or problems
with COBRA or Cal-COBRA, you can
reach the appropriate state or
federal agency by referencing the
contact information available in the
resources section of this brochure.
Important Points to Remember
About COBRA and Cal-COBRA:
-
COBRA is federal law that
extends your current group
medical coverage after a
qualifying event. Individual
policies do not qualify for
COBRA.
-
COBRA law applies to group
policies in force with 20 or
more employees covered on more
than 50 percent of its typical
business days in the previous
calendar year.
-
Indemnity policies, HMOs, PPOs,
and self-insured plans are COBRA
eligible. Federal government
employee plans and church plans
are COBRA exempt.
-
Cal-COBRA is California law that
closely follows federal COBRA.
-
Cal-COBRA law applies to group
policies in force with 2-19
employees covered. Like COBRA,
individual policies do not
qualify for Cal-COBRA.
-
Only indemnity policies, PPOs,
HMOs, and church plans are
Cal-COBRA eligible.
-
You can contact the DOL-EBSA for
questions regarding COBRA law.
-
You can contact either the CDI
(on indemnity policies) or the
DMHC (on HMO/managed care plans)
for questions regarding
Cal-COBRA law.
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In 1996 the federal government
passed into law the Medical Insurance
Portability and Accountability Act (HIPAA).
HIPAA law provides eligible
individuals who have recently lost
their
employer sponsored group
medical plan the opportunity to
purchase medical insurance coverage
even if they have a preexisting
medical condition. If you meet the
definition of an eligible
individual, all
medical insurance
companies who sell individual plans
must offer you medical insurance
regardless of your medical history.
This requirement to issue insurance
is called "guaranteed issue." You
may not be declined coverage based
on medical reasons. In order to
qualify as an eligible individual
you must meet the following
conditions:
-
Your last medical care coverage
must have been under an
employer
sponsored group medical plan,
which includes COBRA or
Cal-COBRA continuation coverage,
for at least 18 months. This
prior 18-month coverage is
referred to as "creditable
coverage."
-
All available COBRA or Cal-COBRA
continuation coverage has been
elected and exhausted. If you
qualify for COBRA or Cal-COBRA
you are required to accept the
coverage and continue the
coverage for the maximum time
period allowed. (When an
employer terminates its existing
group medical plan entirely,
COBRA or Cal-COBRA coverage ends
and is considered exhausted.)
-
You are not eligible under a
group medical plan, Medicare,
Medi-Cal, and/or do not have
other medical insurance coverage.
-
You did not lose your most
recent medical coverage due to
nonpayment of premium or fraud.
Once COBRA or Cal-COBRA has been
exhausted, you have 63 days to file
an application to purchase a
guaranteed issue HIPAA policy with
an insurance company or medical plan.
All carriers that
sell individual
medical care policies must offer
their two most marketed individual
plans to HIPAA eligible individuals
regardless of your medical status. If
you accept a conversion policy or a
short-term policy after exhausting
COBRA or Cal-COBRA, you give up your
HIPAA eligibility. It is important
to understand that a conversion
policy is not a HIPAA policy.
When applying for a HIPAA policy you
can present a Certificate of
Creditable Coverage from your
insurance company or medical plan as
part of the application process. The
Certificate of Creditable Coverage
is a written statement from your
insurance company or medical plan
showing the length of time you have
been covered. The Certificate can be
used as proof of your 18 months
continuous creditable coverage when
applying for a HIPAA policy.
Although HIPAA is federal law, as of
January 1, 2001, California state
law generally conforms with HIPAA.
Depending on the type of coverage
you have (indemnity or HMO), you can
contact either the CDI or the DMHC
if you are experiencing problems
securing a HIPAA policy. Please see
the contact information in the
resources section of this brochure
to reach the CDI or DMHC regarding
HIPAA questions.
Important Points to Remember
About HIPAA:
-
HIPAA gives eligible individuals
who have lost group coverage the
opportunity to purchase
individual medical coverage.
-
HIPAA eligible individuals are
not subject to medical
underwriting.
-
HIPAA policies must be issued to
eligible individuals on a
guaranteed issue basis
regardless of any preexisting
medical condition.
-
You have only 63 days after
COBRA or Cal-COBRA has been
exhausted to file an application
to purchase a HIPAA policy.
-
HIPAA policies are not
conversion policies. Accepting a
conversion or short-term policy
terminates your HIPAA
eligibility.
-
You may contact the CDI or the
DMHC depending on the type of
coverage you have (indemnity or
HMO) if you are experiencing
problems with HIPAA.
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The state of California offers
specialty programs and/or assistance
programs to those who do not qualify
for medical insurance due to
preexisting conditions or income
restrictions, and for small
employers of 2 to 50 workers.
Contact information for each of the
programs is available in the
resources section of this brochure.
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The Major Risk Medical Insurance
Program (MRMIP) offers limited
medical insurance benefits to
California residents who are unable
to purchase medical insurance due to
a preexisting medical condition. If
you have a preexisting condition and
are not eligible for COBRA,
Cal-COBRA, or HIPAA, then you can
apply to MRMIP as a last resort to
obtain medical coverage. This program
provides medical care coverage
through contracted medical insurance
companies and medical plans. MRMIP is
partially subsidized; however,
qualifying participants must pay a
portion of the premium, which can be
costly. Since there are few options
for the medically uninsurable in
California, the waiting list for
MRMIP can be long. MRMIP is under
the jurisdiction of the Managed Risk
Medical Insurance Board (MRMIB).
Recent legislation has created a
36-month limit for participation in
MRMIP. At the end of this period,
MRMIP enrollees are given a one-time
opportunity to purchase guaranteed
issue medical coverage through any
indemnity policy, PPO, or HMO
currently offering
individual medical
coverage in California. Eligible MRMIP participants who are "disenrolling"
after the 36-month period have 63
days to apply for individual medical
coverage. Ninety days prior to the
disenrollment, MRMIP participants
receive a notice of disenrollment
and 45 days prior to disenrollment,
participants are mailed a
Certificate of Program Completion
that enables them to obtain
individual medical coverage.
All indemnity insurance companies,
PPOs, and HMOs who offer
comprehensive individual medical
coverage in California are required
to offer a Standard Benefit Plan
that is substantially the same as
the medical coverage offered while on MRMIP. These Standard Benefit Plans
are the only medical coverage
required to be offered on a
guaranteed issue basis and are
separate from other individual
medical coverage that is available in
the marketplace. If you have
questions on the Standard Benefit
Plans that are being offered,
contact the CDI or the DMHC
depending upon the type of
individual coverage you want to
elect (indemnity or HMO).
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Originally designed to protect
children of low income parents, the
Medicaly Families Program provides
low cost medical, dental, and vision
coverage to children whose parents
earn too much to qualify for public
assistance, but do not earn enough
to
purchase comprehensive major
medical coverage for their children.
The Medicaly Families Program is
administered by MRMIP. There is a
current proposal to expand the
Medicaly Families Program to include
the parents of eligible children
through special federal funding.
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In an effort to
expand prenatal and
preventive care
for pregnant women, California
established the Access for Infants
and Mothers Program (AIM). AIM is
administered by a five-person board
that has established a comprehensive
benefits package that includes both
inpatient and outpatient care for
program enrollees.
Pregnant women of
low to moderate income are eligible
for the program and participate in
the cost of medical care services by
paying a reduced premium. The state
of California subsidizes AIM to make
up for the full cost of the program
benefits.
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Most
supplemental medical
insurance policies are designed to
pay in addition to your
comprehensive major medical
coverage. These supplemental
policies should not be used as a
substitute or replacement for a
traditional medical insurance policy
or a medical plan. Supplemental
medical insurance can pay limited
benefits such as a daily dollar
amount if you are hospitalized
(hospital income policy) or a lump
sum dollar amount if you are
diagnosed with a specified or named
disease, such as cancer. This type
of supplemental policy can also be
structured to pay expenses incurred
in the treatment of the specified
disease. Sometimes this insurance
provides payment over and above your
medical expenses. It is important
that you understand the limitations
and exclusions of supplemental
medical insurance policies and how
the policies coordinate benefits, so
that you can make the best decision
based on your needs and your budget.
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Access for Infants and Mothers
Program (AIM)
P.O. Box 15248
Los Angeles, CA 90015
Phone: 800-433-2611
Web site:
www.mrmib.ca.gov/MRMIB/AIM.html
California Association of Medical
Underwriters (CAHU)
P.O. Box 1071
Fresno, CA 93714
Phone: 800-322-5934
Web site:
www.cahu.org
U. S. Department of Labor
Employee Benefits Security
Administration (DOL-EBSA)
Southern California
1055 E. Colorado Blvd., Suite 200
Pasadena, CA 91106-2341
Phone: 626-229-1000
Phone: 866-444-3272
Northern California
71 Stevenson Street, Suite 915
San Francisco, CA 94105
Phone: 415-975-4600
Phone: 866-444-3272
Web site:
www.dol.gov/ebsa
Department of Managed Medical Care
(DMHC)
980 Ninth
Street, Suite 500
Sacramento, CA 95814-2725
Phone: 888-466-2219
Web site:
www.dmhc.ca.gov
Medicaly Families Program
P.O. Box
138005
Sacramento, CA 95813-8005
Phone: 800-880-5305
Managed Risk Medical Insurance
Program (MRMIP)
P.O. Box 9044
Oxnard, CA 93031-9044
Phone: 800-289-6574
Web site:
www.mrmib.ca.gov
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Assignment of Benefits -
Your signed authorization to
your doctor or hospital (medical
provider) assigning payment to be
made directly to them for your
medical treatment.
Business Day
- Every day that insurance companies
are open for business, which
excludes Saturday, Sunday, and state
and federal holidays.
Calendar Day -
Every day of the calendar month,
which includes Saturday, Sunday, and
state and federal holidays. However,
if any action tied to a time frame
in an insurance policy or CDI
regulation or code falls on a
Saturday, Sunday, or state or
federal holiday; then the action is
postponed to the next calendar day
that does not fall on a Saturday,
Sunday, or state or federal holiday.
Certificate of Coverage
- A document issued to a member of a
group medical insurance plan showing
evidence of participation in the
insurance.
Certificate of Creditable
Coverage - A written
statement from your prior insurance
company or medical plan documenting
the length of time you were covered.
Creditable Coverage or Prior
Qualifying Coverage - The
number of months you had
medical
insurance in place before your
current or new policy became
effective. Creditable coverage must
be counted towards any preexisting
condition exclusion in either an
individual or group policy.
Claim - A
notification to your insurance
company that payment is due under
the policy provisions.
Copayment - The
portion of charges you pay to your
provider for covered medical care
services in addition to any
deductible.
Coverage - The
scope of protection provided by an
insurance contract which includes
any of the listed benefits in an
insurance policy.
Denial - An
insurance company decision to
withhold a claim payment or
preauthorization. A denial may be
made because the medical service is
not covered, not medically
necessary, or experimental or
investigational.
Deductible - A
fixed amount which is deducted from
eligible expenses before benefits
from the insurance company are
payable.
ERISA - Stands for
the Employee Retirement Income
Security Act (1974). Administered by
the U.S. Department of Labor,
Employee Benefits Security
Administration. ERISA regulates
employer sponsored pension and
insurance plans (self-insured plans)
for employees.
Exclusions and/or
Limitations - Conditions or
circumstances spelled out in an
insurance policy which limit or
exclude coverage benefits. It is
important to read all exclusion,
limitation, and reduction clauses in
your medical insurance policy or
certificate of coverage to determine
which expenses are not covered.
Experimental and/or
Investigational Medical Services
- A drug, device,
procedure, treatment plan, or other
therapy which is currently not
within the accepted standards of
medical care.
Grace Period - A
specified period immediately
following the premium due date
during which a payment can be made
to continue a policy in force
without interruption. This applies
only to Life and Medical policies.
Check your policy to be sure that a
grace period is offered and how many
days, if any, are allowed.
Guaranteed Issue -
A medical insurance policy that must
be issued regardless of any
preexisting medical condition. The
present and past physical condition
of a
medical insurance applicant is
not considered as a part of
underwriting. No physical
examination is required. The
insurance company cannot
decline
coverage to an applicant of a
guaranteed issue policy based on
medical history.
Independent Medical Review
- A process where expert medical
professionals who have no
relationship to your medical
insurance company or medical plan
review specific medical decisions
made by the insurance company.
California law provides for an
Independent Medical Review Program,
which is administered by the CDI and
the DMHC depending upon what type of
coverage you have (indemnity or
HMO).
Medically Necessary
- A drug, device, procedure,
treatment plan, or other therapy
that is covered under your medical
insurance policy and that your
doctor, hospital, or provider has
determined essential for your
medical well-being, specific
illness, or underlying condition.
Policy - The
written contract between an
individual or group policyholder and
an insurance company. The policy
outlines the duties, obligations,
and responsibilities of both the
policyholder and the insurance
company. A policy may include any
application, endorsement,
certificate, or any other document
that can describe, limit, or exclude
coverage benefits under the policy.
Preexisting Condition
- Any illness or medical
condition for which you have
received medical advice or treatment
during the six months prior to
obtaining medical insurance. Group
medicalcare policies cover
preexisting conditions after you
have been insured for 6 months, and
individual policies cover
preexisting conditions after you
have been insured for 1 year.
Reference CIC Section 10198.7.
Creditable coverage must be counted
towards any preexisting condition
exclusion in either an individual or
group policy.
Usual, Reasonable, and
Customary - The amount that
your insurance company determines is
the normal payment range for a
specific medical procedure performed
within a given geographic area. If
the charges you submit to your
medical insurance company are higher
than what is considered normal for
the covered medical care services,
then your medical insurance company
may not allow the full amount
charged to you.
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