Frequently Asked Questions

General Health Insurance
Group Health Insurance
Managed Care

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://dhfs.wisconsin.gov/em/imagencies/index.htm).

Group Health Insurance

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.

My ex-spouse and I each have group health insurance coverage, insuring our children. Whose policy should pay first on claims submitted to both companies?

Generally benefits for the children are determined in the following order; first, the plan of the parent with custody of the children; second, the plan of the new spouse of the parent with custody of the children; third the plan of the parent not having custody of the children.

What if the divorce decree specifically names one of the parents responsible for the children's health care expenses?

In such a case, the plan of the responsible parent pays first. If the court decree states parents have joint custody and doesn't name one parent responsible for the children's health care expenses, or if the court decree states both parents are responsible for the children's health care expenses, but gives only one parent actual custody, the plan of the parent whose birthday falls earlier in the year pays first. If both parents have the same birthday, the plan that covered the parent longer, pays first.

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 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.

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.

Who has continuation and conversion rights?

Under Wisconsin law, the right to continue group insurance coverage or to convert to an individual policy applies to: a former spouse whose coverage ends because of divorce or annulment; a group member who is no longer eligible for coverage under a group policy, as well as the covered spouse or dependents, except an employee who is fired for misconduct; and the covered spouse or dependent of a group member who dies. The federal COBRA law, which applies only to employers with 20 or more employees, also allows certain persons the right to continue group coverage.

Who is responsible for notifying people of their rights to continuation or conversion?

The employer is required to provide notice in the case of group coverage. If a couple is covered under an individual (not group) policy and coverage of one spouse ends because of divorce or annulment, the insurer is responsible for giving notice to the former spouse of the right to obtain his or her own individual policy.

How long does a former employee have to sign up for continuation of health insurance?

Under Wisconsin insurance law, the former employee must elect to continue the insurance and submit the premium to the employer within 30 days from the date of the employer's notice.

What happens if someone is not notified of his or her rights?

Group coverage continues until notice is given if the required premium continues to be paid. If coverage terminates, the aggrieved party may have a basis for a civil action against the employer or former spouse. Wisconsin insurance law does not make another party responsible for a terminated insured's medical expenses.

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.

Managed Care

How do I select a health plan?

Before you make a selection, carefully compare the plans available in your area. 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. Be prepared to make some tradeoffs.

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.

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 do the Medical Expense Ratio and Administrative Expense Ratio tell me?

The Medical Expense Ratio represents the percentage of premiums that are used to pay for the delivery of health care. The Administrative Expense Ratio depicts the percentage of total revenue used to administer the plan. In theory, a company with a low administrative expense ratio would be operating more efficiently than a company with a high ratio. Caution should be used in interpreting the results, however, since too low of a ratio may be indicative of an understaffed plan, and certain activities such as accreditation of the plan's quality improvement and assurance program is expensive and would increase the ratio. The accreditation program is considered by many to be in the member's best interest. The ratio results could raise questions that should be addressed by the plan.

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 for 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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