General Health Insurance

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 individual major medical insurance policy states it will pay 100% after my deductible has been satisfied. When I submitted a claim, the company only paid a portion of the balance because the charges exceeded the usual, customary, and reasonable charge. What does the company mean by usual, customary, and reasonable charge?

Most insurance companies do not always pay the total amount you are billed by your medical provider. Companies have their own fee schedule, often known as usual, customary, and reasonable (UCR) charges to calculate their payments. The UCR charges are typical amounts paid in your area for everything from a doctor's visit to heart surgery. If your doctor/provider charges higher than the insurance company's UCR charge, you may have to pay the difference.

How does an insurance company determine usual, customary and reasonable charges?

Insurers collect data from their own experience or from other sources reflecting the fees charged by health care providers in a particular geographic area for a specific service or procedure. Generally, the data is collected by zip code area or other regional basis. The data must be updated every six months and can be no more than 18 months old. Insurers then establish a certain percentile from the data they collect to determine what the company's usual and customary fee will be for a specific service. Charges below that percentile are considered for payment. Since usual, customary and reasonable fees do not contemplate situations where there were complications or additional procedures performed, if your doctor has information concerning extenuating circumstances or complications which would justify a higher fee, the information should be forwarded to the insurer for further review.

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 choose 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.

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.

I just applied for health insurance and had an appendicitis attack the next day. However, the health insurance company I applied for said that treatment was not covered since they had not issued the policy. Can that be true?

Yes. Health insurance is not like your homeowner or auto insurance where you can typically make it effective on the date of application. Health insurance policies usually must be approved by the insurance company before they are effective. If you have a serious illness or injury, which arises between the time you apply for coverage and the time the company issues the policy, you should inform your agent as it may affect your eligibility for coverage. It is a good idea if you already have a health insurance policy and are applying for new coverage to keep the first policy in force until the new one is issued.

I am planning on having surgery in the near future. My doctor's office says I need to check and see if precertification is required by my insurance carrier. What is precertification?

Precertification is a requirement found in many health insurance policies. It means that, except in an emergency, you must have certain medical services okayed in advance. Your insurance contract may have such a requirement. If you do not obtain precertification, you may be required to pay a copayment or coinsurance amount, a specific dollar penalty or the insurer may deny benefits. Obtaining precertification does not automatically mean benefits will be paid for the medical services you receive. Your coverage is dependent on the provisions of your policy, including any preexisting condition waiting period.

My insurance company refuses to pay my hospital emergency room bill saying that it was not an emergency. Can they do this?

Every health care plan offered in Wisconsin that covers emergency care, must cover services in a hospital emergency facility that are required to evaluate and stabilize a condition that, because of severe pain or symptoms, leads a prudent layperson with average knowledge of health and medicine to reasonably conclude that a lack of immediate medical attention will result in serious jeopardy to the person's health, serious impairment to the person's bodily functions or serious dysfunction of one or more of the person's body organs or parts. The insurer may not require prior authorization for coverage of emergency medical conditions.

My health insurance premiums keep going up. What can I do?

As with any major purchase, it is wise to shop around to make sure you are getting the most for your money. Make sure you find the insurance product that best fits your needs. There are several ways you may be able to lower your premium including: paying a higher deductible and/or copayment; increasing your maximum out-of-pocket payment; reducing or dropping coverage for certain services. Be careful not to give up an essential benefit.

Why do insurance companies keep raising premiums?

Premiums for health insurance have increased across-the-board in recent years as health insurers have experienced increased claim costs. These increases are due in part to increased medical costs, people utilizing more services, and advances in medical technology. As claim costs increase, premiums must also be increased to ensure there are sufficient funds for future claims.

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 Customer Service
1751 W. Broadway
P.O. Box 8961
Madison, WI 53708-8961
1-800-828-4777 or (608) 221-4551
http://hirsp.org

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

BadgerCare is Wisconsin's newest 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; you must not be covered by any other health insurance; and there is no asset test.

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. You can be sure it's a good investment in your family's health.

If you think you might be eligible, apply online at access.wisconsin.gov (https://access.wisconsin.gov/access/) or contact your Local County/Tribal Human or Social Services Agency (http://dhs.wisconsin.gov/em/imagencies/index.htm).