What Rights Do I Have as a Health Insurance Consumer?

If you purchased insurance coverage from a licensed insurer you have the benefit of many important protections.

COBRA Continuation Coverage
If you purchase insurance coverage through your employer and your employer has 20 or more employees, you are entitled to continuation coverage by the federal Consolidated Omnibus Budget Reconciliation Act (COBRA). Your state may require continuation coverage to be offered by smaller employers – typically those with less than 20 employees.

Under COBRA, if you leave your current job you have the option to continue your health care coverage for up to 18 months. You are required to pay the full premium yourself, even if your employer paid part of your premium while you were employed, and the employer may charge an additional, limited administrative fee. You can find out more about COBRA continuation of group health benefits from the Federal Department of Labor Office of Employee Benefits Security Administration site.

To be an “eligible individual,” you must meet all of the following criteria:

• You must have had 18 months of continuous creditable coverage, with at least the last day having been under a group health policy (coverage is considered continuous if it is not interrupted by a break of 63 or more consecutive days).

• You must have used up any COBRA group continuation coverage for which you were eligible. See the above section for information on COBRA.

• You must not be eligible for Medicare, Medicaid or a group health policy.

• You must not have other major medical health insurance.

• You must apply for health insurance for which you are deemed an “eligible individual” within 63 days of losing your prior coverage.

HIPAA
HIPAA is the Health Insurance Portability and Accountability Act of 1996. It limits insurers’ power to deny or delay claims, reduces your chances of losing existing coverage, makes it easier and less risky to switch health plans, and prohibits insurance discrimination based on health problems.

Key HIPAA Protections

• Non-Discrimination
  In a group plan, the insurer may not apply different eligibility rules, offer different benefits, or charge a higher premium to any individual on the basis of certain “health factors” – health status, claims experience, medical history or genetic information.

• Guaranteed Issue
  Insurers providing small group coverage must offer coverage to any small employer that applies, regardless of health status or prior claims experience of the employees.

• Guaranteed Renewability
  Insurers may not cancel a health plan unless the beneficiary fails to pay the premiums or the insurer stops doing business in the market.

• Limits on Preexisting Condition Exclusions
  Insurers may not exclude (refuse to cover) treatments and services related to medical conditions that existed before the beneficiary purchased the health plan for a period more than 12 months. If the person has had continuous coverage prior to purchasing the new plan there can be no coverage exclusions.

State Consumer Protections
States provide a variety of important protections through state law. These may include: the appeal of coverage decisions within the insurance company; the appeal of coverage decisions to an impartial external reviewer; prompt payment of claims; access to certain specialists and health care providers; coverage of specific treatments and services; and many more.

Every state has an insurance department that is ready to help you with any question or complaint you may have about your coverage. To find out more, contact your state insurance department.