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Health Insurance - General - Top Ten Questions

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For additional information, please also visit our Health Insurance Resource Center. Additional Frequently Asked Questions are available by selecting this link.

  1. What does the policy cover, ie. drugs?

    In accordance with 3217-a the company must provide a description of coverage provisions; health care benefits; benefit maximums, including benefit limitations, and exclusions of coverage, including a definition of medical necessity used in determining whether benefits will be covered.

  2. Does my current primary care physician participate with the carrier?

    In accordance with 3217-a a description of procedures for insureds to select and access the insurer’s primary and specialty care providers, including notice of how to determine whether a participating provider is accepting new patients.

  3. Can I be denied for a pre-existing condition and for how long ?

    According to section 3232, no pre-existing condition provision shall exclude coverage for a period in excess of twelve months following the enrollment date of coverage for the covered person and may only relate to a condition regardless of the cause of the condition, for which medical advice, diagnosis, care or treatment was recommended or received within the six-month period ending on the enrollment date. The Company shall credit the time the covered person was previously covered under creditable coverage, if the previous creditable coverage was continuous to a date not more than 63 days prior to the enrollment date of the new coverage.

  4. Can I get a list of participating physicians?

    In accordance with 3217-a a description of procedures for insureds to select and access the insurer’s primary and specialty care providers, including notice of how to determine whether a participating provider is accepting new patients.

  5. My spouse just lost the job, what can I do to continue the coverage without a coverage penalty?

    According to section 3221(m) if an employee loses coverage because of termination of employment such employee or member shall be entitled without evidence of insurability upon application to continue his hospital, surgical or medical expense insurance for himself or herself and his or her eligible dependants, subject to all of the group policy’s terms and condition applicable to those forms of benefits and certain conditions.

  6. Is there a lifetime claim limit?

    Defined in policy.

  7. If a claim is denied what can I do to appeal the carrier’s decision?

    In accordance with article 49 the Company must have an internal appeal system for adverse determinations. In the case of denials for medical necessity and experimental/investigational claims, the member shall be entitled to an internal appeal as well as an external appeal.

  8. What happens if I go to a non-participating physician?

    If there is network only coverage, there is no coverage for non-participating physicians, unless approval is granted to go outside the network. If out-of-network coverage is available, you would be subject to deductible and co-insurance.

  9. If I am currently receiving services from a physician and change plans will the services be paid even if the doctor is not a member of the plan?

    In accordance with section 4804, if a new insured whose health care provider is not a member of the insurer’s in-network provider network enrolls in the managed care product, the insurer shall permit the insured to continues an ongoing course of treatment with the insured’s current health care provider during a transitional period of up to 60 days from the effective date of enrollment, if life-threatening disease or condition or a degenerative and disabling disease or condition or the insured has entered the second trimester of pregnancy at the time of enrollment

  10. What is the age or other requirements for a person to receive dependent status?

    Defined in the policy.

 

  1. Is a high-deductible policy available?
  2. Is short-term coverage available?
  3. Why is coverage so expensive?
  4. What happens if I change employers?
  5. What is indemnity health insurance?
  6. I have been recently diagnosed with a serious illness.  Can my insurer drop my coverage because of this?  Can my rates go up because of this?
  7. What are my rights as a policyholder?
  8. How do I file a complaint or inquiry against my health insurer?
  9. Other than cost, what should I look for in a standardized HMO plan?
  10. Am I eligible for any government subsidized health insurance plans (CHP, Healthy New York, Family Health Plus etc.)?