Understanding Your Rights as a Health Care Consumer

This article will explore the rights you have as a health care consumer in the State of Ohio. We will review how an individual can obtain coverage upon leaving an employer and discuss protection provided should an individual seek to change jobs and be worried about how a current health condition might affect future coverage. Also we will explore how to appeal a denied claim and explore the State of Ohio’s basic requirements of mandated coverage.

Termination of group policy

Conversion

An individual who terminates employment with their employer has several ways to protect themselves.

Individuals can get basic or standard coverage through conversion rights provided the employee has been covered continuously for one year you can year keep this policy as long as premiums are paid. Premiums for conversion policies can be obtained from the insurer by contacting customer service. The pricing for these products is often prohibitive for the recipient.

State Continuation

The State of Ohio allows any individual who is not eligible to continue coverage under COBRA requirements and is eligible for unemployment, to get 6 months of continuation under their employer’s plan. The recipient will be able to obtain state continuation coverage for the same price that the group is paying for the policy.

COBRA

Consolidated Omnibus Budget Reconciliation Act (COBRA) allows an individual, who is terminating employment with a qualified employer, to purchase health insurance for up to 36 months upon termination. Typically the individual will qualify for 18 months of coverage and these premiums must be paid by the individual and remitted to either the employer or the carrier. The pricing for COBRA coverage generally has a 2% administrative load and will be the true cost the employer pays for the coverage.

HIPAA

Health Insurance Portability and Accountability Act (HIPAA) is a recent complex law that has many facets of compliance. As the name implies, HIPAA provides portability for the consumer. This portability does not mean you take your current policy and go to another employer with this policy, rather you will receive a Certificate of Creditable Coverage that proves you have had coverage. Then you will not be subjected to any pre-existing condition limitations. If an individual has not had 6 months of prior coverage, HIPAA guidelines will allow the carrier to impose up to a 12-month pre-existing condition limitation. HIPAA has allowed individuals who feared not getting coverage the freedom to move jobs and ensure their ability to obtain future health insurance.

Appeals

After an individual completes the insurance companies internal appeals process without resolving your concerns, Ohio law may allow your case to qualify for review by an independent company. There are many requirements for your appeal to go to external review and this article will not allow us space to explore all of the requirements. However, if an appeal has not worked successfully at the health insurer, contact the Department of Insurance at 800-686-1526 to learn more about what you can do.

State mandated minimum benefits

The State of Ohio has some basic benefits that must be part of any policy that a group offers. There must be basic coverage for alcoholism, mental illness, kidney dialysis, pap smears and mammograms. A group policy cannot discriminate against certain types of licensed health professionals. The health insurers are required to pay for “any legally approved drug your doctor prescribes.” So you should ensure that these items are covered. Always review your policy to understand what is covered!

Open Enrollment

During Open Enrollment a carrier cannot decline coverage for anyone who applies for coverage. For employers who offer group policies, open enrollment occurs for your employer during the month preceeding your group policy renewal. During this month, employees can apply for coverage and cannot be rejected due to health conditions. However, if someone is hospitalized for a chronic condition or permanent injury they do not qualify.

In addition Public Open Enrollment will enable anyone regardless of health status to apply and obtain coverage. There are some catches however. Each health insurer has limited seating and once the seats are filled, no more open enrollees will be accepted. Secondly, the cost are very high. The carriers are required to advertise their open enrollment in print media. Each company has a different time during the year to offer Open Enrollment so you often can see these advertisements in the classified advertisements of the larger periodicals.

Conclusion

As health care consumers we have legal recourse should a health insurer decline a claim. In addition, we have rights to allow us to move from job to job without the fear of being rejected for health insurance. Contact the Ohio Department of Insurance to get more information for your rights as an Ohio health care consumer.