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General Health Insurance

  • Where can I obtain health insurance?
  • My health insurance company is nonrenewing my individual policy. Can they do this?
  • It looks like I can save a lot of money by switching my health insurance. Are there any differences between health insurance policies?
  • My health insurance policy includes a deductible and coinsurance. What does this mean?
  • My agent delivered my individual health insurance policy last week. I've changed my mind and do not wish to keep this policy. Can I get a refund?
  • What can I do if I can't find health insurance?
  • What can I do if I can't afford health insurance?

Group Health Insurance

  • I am covered by a group health plan through my employer. I would like to receive a copy of the certificate of insurance. How do I go about obtaining a copy?
  • My employer has told us that we will be going to a self-insured arrangement with our health insurance. What does this mean for me?
  • I heard about a law that allows you to take your medical coverage with you when you change jobs. Is this true?
  • What is meant by the term "preexisting condition"?
  • Are there preexisting conditions that cannot be excluded from group coverage?
  • I will be leaving my job in a couple of weeks and I am worried about my health insurance. Is there any way I can keep my group insurance coverage?
  • My job was terminated and my employer went out of business. Can I continue my group health insurance coverage?

Managed Care Plans

  • How do I select a health plan?
  • In completing the application, I had to choose a primary care provider. What does it mean?
  • What can I do if I want a different primary care provider?
  • What happens if I need care immediately?
  • Does it matter if the specialist to whom I am referred is a plan provider?
  • My primary care provider referred me to a nonplan provider. Do I have to contact the insurance company before my appointment?
  • How are students or dependents living out of the service area covered?
  • May I use any provider I choose under the plan?
  • Will I incur any liability if I fail to follow the preauthorization requirements?
  • What is a drug formulary?
  • What if I have a complaint?
  • My doctor told me he was no longer with the HMO, but I want to stay with him. What can I do?
  • My doctor never told me he was no longer with the HMO and the HMO did not tell me either. Now I have all these bills the HMO will not cover. What can I do?
  • I disagree with my doctor and want a second opinion. Will the HMO pay for it?
  • I live in a different county from where I work and my employer only offers an HMO. It is too far for me to go to see the doctor. What can I do?
  • What is a defined network plan?
  • I received a provider directory when I enrolled in my health plan. How do I know whether I'm in an HMO, a preferred provider plan (PPP), or some other type of managed care plan? What difference does it make?

Long-Term Care and Medigap Insurance

  • What is long-term care and should I buy long-term care insurance?
  • Does Medicare cover long-term care services?
  • Can my long-term care insurance premiums be increased?
  • Can the insurance company cancel my long-term care insurance policy?
  • How do I qualify for long-term care insurance?
  • Are preexisting conditions covered under long-term care insurance policies?
  • Are Alzheimer's and other dementias covered by long-term care insurance?
  • What is an elimination period?
  • Are benefits paid for all institutional settings, such as community based residential facilities (CBRFs), assisted living facilities, and residential care facilities?
  • How much does a stay in a nursing home cost?
  • Why do I need a Medigap insurance policy?
  • If I buy a Medicare supplement insurance policy, will I be able to go to my usual doctor and hospital for care?
  • What paperwork will I receive from my Medigap insurer?
  • What is Medicare select?
  • If I switch from health insurance provided by my or my spouse's current or former employer or union to a Medicare health plan, can I switch back to the employer/union insurance if I disenroll from the Medicare health plan?

General Health Insurance

Where can I obtain health insurance?

The best way to obtain health insurance is by contacting local area health insurance agents. They can look for ways to get you the most protection at an affordable cost. Agents and companies are listed alphabetically and by location in the yellow pages of your telephone directory. Insurance premiums can vary substantially from company to company so it usually pays to check with several companies before making a final choice.

My health insurance company is nonrenewing my individual policy. Can they do this?

If your policy is not guaranteed renewable, the company can exercise its right to nonrenew your policy. Nonrenewal refers to the termination of a policy at the expiration date. If an insurer decides it does not want to renew your policy, it must mail or deliver to you a nonrenewal notice at least 60 days before the policy's expiration date. The nonrenewal notice must provide the reason for the nonrenewal.

Even if your policy is guaranteed renewable, the company can nonrenew your individual policy with 90 days notice if it nonrenews all policies of that type in the state and offers you any other type of individual health policy that the insurer offers individuals. The company can also nonrenew your individual policy with 180 days notice if it nonrenews all individual health policies in the state.

It looks like I can save a lot of money by switching my health insurance. Are there any differences between health insurance policies?

Yes, there can be substantial differences in the benefits offered between policies. If the premiums are significantly different there is a strong likelihood that the cheaper policy provides much less coverage. The old adage, you get what you pay for, is often true with health insurance. When comparing the price of insurance policies it is important to carefully analyze the benefits between policies. If you have difficulty interpreting the differences, you may wish to have someone who is knowledgeable assist you in making this very important decision.

My health insurance policy includes a deductible and coinsurance. What does this mean?

A deductible is the initial dollar amount you must pay out-of-pocket before an insurance company pays its share. It is usually a flat dollar amount. Usually the higher the deductible, the lower the premium. Coinsurance is the share or percentage of covered expenses you must pay in addition to the deductible. For example, your policy may pay 80% of covered charges after you pay the deductible. You would then pay the remaining 20% as coinsurance until a maximum out-of-pocket expense is reached.

My agent delivered my individual health insurance policy last week. I've changed my mind and do not wish to keep this policy. Can I get a refund?

Yes. According to Wisconsin law, you have the right to return the policy within ten (10) days after receiving it if you are not satisfied for any reason. If you chose to do so, the premium you paid will be refunded in full. If you purchase a Medicare Supplement policy, a Medicare Select policy, or a long-term care policy, you have the right to return the policy or certificate within thirty (30) days of receipt and receive a full refund.

What can I do if I can't find health insurance?

The Wisconsin Health Insurance Risk Sharing Plan (HIRSP) offers health insurance to Wisconsin residents who, due to their medical conditions, are unable to find adequate health insurance coverage in the private market. Information on HIRSP may be obtained by contacting:

HIRSP
1751 W. Broadway
P.O. Box 8961
Madison, WI 53708-8961
800-828-4777 or
(608) 221-4551

What can I do if I can't afford health insurance?

BadgerCare is Wisconsin's program to assist lower income, working families obtain health insurance at a reasonable price. To be eligible for BadgerCare, you must meet all of the following criteria: you must have children under age 19 living with you; your income must be within the guideline limits; and you must not be covered by any other health insurance.

BadgerCare provides a comprehensive health benefit package. If you would like more information about BadgerCare, contact your County Department of Social or Human Services Office, your Certifying Tribal Agency, or call 800-363-3002.

Some families will need to pay a premium. You may not have to pay at all, but if you do, the amount you pay depends on your family income. If you think you might be eligible, call 1-800-362-3002 (TTY and translation services available).

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Group Health Insurance

I am covered by a group health plan through my employer. I would like to receive a copy of the certificate of insurance. How do I go about obtaining a copy?

Under Wisconsin insurance law health insurers are required to provide insureds with a copy of the health insurance certificate. You should have received a letter from your insurer telling you how to get a copy of the certificate. The Office of the Commissioner of Insurance has taken a position on the method of providing the information. Health insurers can inform individuals, in writing, that the health insurance certificate is available and can be printed from its Internet Web site. The correspondence must also include an offer to provide a paper copy of the certificate if an insured requests it.

My employer has told us that we will be going to a self-insured arrangement with our health insurance. What does this mean for me?

It means that your employer has established its own plan to help cover employees' health care expenses. Sometimes employers do this and have the health plan administered by an insurance company or other firm; but sometimes there is no outside administrator. With self-insured plans, certain federal laws may apply. You will not have any of the protection state insurance law provides because federal law preempts state jurisdiction over most self-insured plans through the Employee Retirement Insurance Security Act also known as ERISA.

I heard about a law that allows you to take your medical coverage with you when you change jobs. Is this true?

This is only partially true. You do not actually take your exact plan of health benefits with you, but you do get to "take the credit" for the time you were covered under your former plan to your new employer's plan. Under the federal Health Insurance Portability and Accountability Act of 1996 (HIPAA) and Wisconsin insurance law, any preexisting condition waiting period in your new employer's group health benefit plan will be reduced by the amount of time you were covered by your prior employer's group health plan if you do not have a break in coverage longer than 62 days.

What is meant by the term "preexisting condition"?

In a group insurance policy, a preexisting medical condition is defined as a physical or mental condition for which medical advice, diagnosis, care or treatment was recommended or received within six months prior to the insured's enrollment under the plan. Insurance contracts may not cover these preexisting medical conditions for a period of time after you enroll in the plan.

Are there preexisting conditions that cannot be excluded from group coverage?

Yes. Pregnancy cannot be treated as a preexisting condition. If you're pregnant when you join your new group health plan your pregnancy must be covered. Genetic information may not be considered a preexisting condition if there is no specific diagnosis of a disease or medical problem related to the information.

I will be leaving my job in a couple of weeks and I am worried about my health insurance. Is there any way I can keep my group insurance coverage?

If you are leaving a job and not immediately going to work for an employer who offers group health insurance coverage, you may be able to continue your prior group coverage for up to 18 months. However, you will be responsible for the entire premium, both the portion you paid as an employee and the employer contribution as well.

My job was terminated and my employer went out of business. Can I continue my group health insurance coverage?

Continuation rights are not available if no group policy exists. The right to convert to an individual policy providing reasonably similar benefits still applies.

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Managed Care Plans

How do I select a health plan?

Think about what is most important to you in a health plan: low cost; availability of a specific physician, clinic, or hospital; freedom to see any physician you want; or convenient location of facilities. If you like the physician you are currently seeing, check to see if he or she is a provider in the plan you are considering. If you or a dependent has special medical needs, check that the plan you are considering has adequate medical services and providers for that specialty.

In completing the application, I had to choose a primary care provider. What does that mean?

Your primary care provider is responsible for managing your health care needs. Many HMOs require its members to receive all care from the primary care provider or with a referral from the primary care provider.

What can I do if I want a different primary care provider?

Every plan has its own procedures for changing primary care providers. Some plans will only allow you to change primary care providers once during the year. Others allow you to change as often as you like. This should be explained in your member handbook, or your employer may be able to assist you.

What happens if I need care immediately?

If you need emergency care, most plans will allow you to go to the nearest provider. If it is not an emergency but you need care sooner than a routine doctor's visit, you may be required to go to a plan provider. You should always contact your primary care provider or the insurance company as soon as possible. Some plans require you to pay an additional portion of the charges if you do not contact them within 48 hours of receiving care in an emergency room.

Does it matter if the specialist to whom I am referred is a plan provider?

Yes. Most closed panel plans will require you to see a specialist who is a plan provider if one is able to provide the services you need.

My primary care provider referred me to a nonplan provider. Do I have to contact the insurance company before my appointment?

Yes. Most closed panel plans require a referral to a nonplan provider be preauthorized by the insurance company before the appointment. In some cases, your primary care provider may submit the referral request to the insurer for you, and the insurer will send you a notice letting you know if the referral has been approved. In some cases, you may be required to contact the insurer directly. In any case, if you have not received the authorization from the insurance company prior to your appointment, you should contact the company to determine if the service will be covered.

How are students or dependents living out of the service area covered?

Dependents who live out of the area are generally covered for emergency or urgent medical problems. The dependent would be required to receive all follow-up care and routine care from plan providers in the service area.

May I use any provider I choose under the plan?

If you are covered under an HMO or other closed panel plan, you will need to receive all services from your primary care provider or other plan providers. If you are covered under a preferred provider plan or point-of-service plan, you will be able to choose any provider. However, you will be required to pay a larger portion of the bill if you use a nonplan provider, and may be required to have some services preauthorized by the insurance company. Your member handbook should explain the requirements specific to your plan.

Will I incur any liability if I fail to follow the preauthorization requirements?

Yes. If you fail to follow the required preauthorization procedures, you will be required to pay a larger portion of the claim. In some cases, the plan may determine that the service is not covered under the contract and completely deny the claim.

What is a drug formulary?

Many managed care plans establish a list of prescription drugs which the plan considers medically appropriate and cost effective. This formulary often requires a generic form of a drug to be used.

What if I have a complaint?

You should contact the plan's customer service department. Many problems can be resolved on an informal basis. You can also file a written grievance. All managed care plans are required to have a grievance procedure to resolve a member's problems. This procedure is explained in your member handbook. Grievances are generally resolved within 30 days. If you believe your medical condition needs immediate attention, you may wish to ask that the grievance be considered as an expedited grievance. Expedited grievances must be resolved within 72 hours after receipt. You can also file a complaint with OCI at any time during the grievance procedure.

My doctor told me he was no longer with the HMO, but I want to stay with him. What can I do?

The agreement between the managed care plan and your doctor is a separate agreement that may terminate any time during the year.

If the provider is your primary provider, the plan must cover your care for the remainder of the plan year.

If you are in your 2nd or 3rd trimester of pregnancy, the plan must cover your care through postpartum care.

If you are seeing a specialist, the plan must cover your care for the lesser of 90 days or through the current course of treatment.

If the provider leaves the plan because he or she no longer practices in the plan's service area or is terminated for misconduct, the foregoing provisions do not apply.

If your employer offers other plans, you may wish to consider changing plans during your employer's open enrollment period.

My doctor never told me he was no longer with the HMO and the HMO did not tell me either. Now I have all these bills the HMO will not cover. What can I do?

If your doctor leaves the HMO in the middle of the plan year, there are notice requirements. The HMO is required to notify you at least 30 days in advance if its contract with your primary care provider is terminated. If it terminates its contract with a specialist, it must either notify you at least 30 days in advance, or require the specialist to post a notice in the provider's office. If you are receiving bills, you should file a grievance with the plan to explain the extenuating circumstances. You should also file a complaint with OCI.

I disagree with my doctor and want a second opinion. Will the HMO pay for it?

Yes, so long as you go to a plan provider or, if necessary, obtain a referral from your primary provider for the second opinion.

I live in a different county from where I work and my employer only offers an HMO. It is too far for me to go to see the doctor. What can I do?

If you enroll in the HMO, you must follow its procedures. This means that you will be required to receive your care from plan providers. You may wish to ask your employer to consider offering other coverage.

What is a defined network plan?

A defined network plan is the term used in Wisconsin insurance law to refer to any health benefit plan that creates incentives for its enrollees to use network providers. Some defined network plans will provide coverage only if the enrollee uses network providers and other plans will pay a larger portion of the charges if the enrollee uses network providers. HMOs and preferred provider plans are examples of defined network plans. Some people refer to these plans as managed care plans.

I received a provider directory when I enrolled in my health plan. How do I know whether I'm in an HMO, a preferred provider plan (PPP), or some other type of managed care plan? What difference does it make?

When you enrolled, you should have received a certificate of coverage and other written information that explains how your health plan works. This material should describe the benefits covered by your plan and explain any procedures that you must follow in order to receive coverage. It is very important to review this information. It will explain whether you must use plan providers; all of your coverage or whether you can choose any provider. It will also explain when you need a referral from your primary care provider and when you need to contact the health plan for authorization before receiving health care.

If you have any questions about your coverage, call the health plan's customer service department. If you have coverage through your employer, the employer's human resources department may also be able to answer your questions.

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Long-Term Care and Medigap Insurance

What is long-term care and should I buy long-term care insurance?

Long-term care is the kind of help you need if you are unable to care for yourself because of a prolonged illness or disability. It can range from help with daily activities at home, such as bathing and dressing, to skilled nursing care in a nursing home.

Not everyone should buy a long-term care insurance policy. For some, a long-term care policy is an affordable and attractive form of insurance. For others, the cost is too great and the benefits they can afford are insufficient. Buying a long-term care policy should not cause financial hardship and make you forego other more pressing financial needs. Each person should carefully examine his or her needs and resources to decide whether long-term care insurance is appropriate. It is also a good idea to discuss such a purchase with your family.

Does Medicare cover long-term care services?

Medicare provides only limited coverage for long-term care that helps a person to recuperate from a sickness or injury. Medicare pays only for medically necessary skilled nursing care services. You should not rely on Medicare to pay for long-term care needs.

Can my long-term care insurance premiums be increased?

Yes, premiums for all long-term care insurance policies may be increased. However, if premiums are based on issue age, they may only increase if premiums are increased for all individuals insured under the same type of policy. If premiums are based on attained age, premiums will increase as you age.

Can the insurance company cancel my long-term care insurance policy?

No, your policy is guaranteed renewable for life. The policy may terminate only when you cease paying your insurance premiums or if you use the maximum amount of benefits available under the policy.

How do I qualify for long-term care insurance?

Companies selling long-term care insurance underwrite their coverage. That means they look at your current health status and health history and issue a policy only if you meet the guidelines established by the company. Some companies ask only a few questions about your health. Others may ask for more detail, examine your current medical records or ask for a health statement from your doctor.

Answer all questions as truthfully and thoroughly as possible. If a company later learns you did not fully disclose your health status on the application, it could refuse to pay your claim or cancel your policy.

Are preexisting conditions covered under long-term care insurance policies?

Preexisting conditions must be covered by long-term care insurance policies. However, insurance companies may have a preexisting condition waiting period of up to six months. After your policy is in effect for six months, it will pay for covered benefits.

Are Alzheimer's and other dementias covered by long-term care insurance?

Alzheimer's disease and other dementias are required to be covered by long-term care policies. However, if you have Alzheimer's or other dementia at the time you apply for coverage, the insurance company is not required to accept your application or to issue coverage.

What is an elimination period?

An elimination period is similar to a deductible. This means that when you begin using long-term care services, there is a waiting period before the policy begins paying benefits. You are responsible for paying for all expenses during the elimination period.

Are benefits paid for all institutional settings, such as community based residential facilities (CBRFs), assisted living facilities, and residential care facilities?

Long-term care policies pay only those benefits described or defined in the policy. Some policies pay for assisted living facilities, some do not. Most policies do not cover CBRFs or other placement. Read the definitions in your policy carefully.

How much does a stay in a nursing home cost?

The costs of nursing home care vary among facilities and locations. You should contact those facilities that you would consider acceptable and ask about their current daily charges. You can then determine the amount of coverage you will need.

Why do I need a Medigap insurance policy?

Although Medicare covers many health care costs, you still have to pay Medicare's coinsurance and deductibles. There also are many medical services that Medicare does not cover. A Medigap policy provides reimbursement for some of the out-of-pocket costs that are not covered by Medicare and which are the beneficiary's share of health care costs.

If I buy a Medicare supplement insurance policy, will I be able to go to my usual doctor and hospital for care?

Yes. Unlike some types of health coverage that restrict where and from whom you can receive care, Medicare supplement policies generally pay the same supplemental benefits regardless of your choice of health care provider. If Medicare pays for a service, your Medicare supplement policy pays its regular share of benefits.

What paperwork will I receive from my Medigap insurer?

A Medigap insurance company is required to send you an Explanation of Benefits to prove that it paid its portion of your claims for your health benefits. Combined with the Explanation of Medicare Benefits which you receive from Medicare, you will have the total information about how your health care claim was processed.

What is Medicare select?

Medicare select is a type of Medigap policy that is permitted to be sold in Wisconsin. Medicare select policies, which may be offered by insurance companies and health maintenance organizations (HMOs), must meet all the requirements that apply to a Medigap policy. The only difference between a Medicare select policy and a standard Medigap insurance policy is that a Medicare select policy will require you to use doctors and hospitals within its network in order for you to be eligible for full benefits. Medicare, however, will still pay its share of approved charges if the services you receive outside the network are services covered by Medicare. Because of this limitation, a Medicare select policy will usually cost less than a regular Medigap policy.

If I switch from health insurance provided by my or my spouse's current or former employer or union to a Medicare health plan, can I switch back to the employer/union insurance if I disenroll from the Medicare health plan?

If you or your spouse has employer or union-provided health insurance and you disenroll from that group health plan to join another Medicare health plan, you may or may not be able to get the same policy back for the same premium. You should contact your or your spouse's current or former employer or union before you make a health plan choice.