Health Insurance

Health Insurance And You

Health insurance helps you with the cost of general health care and helps you protect yourself and family against illness, injury and accidents. Health plans pay specifies sums for medical expenses or treatment and they can offer many options and vary in their approaches to coverage.

The focus of this page is on health plans that provide coverage for major medical expenses, which include the cost of hospital bills and medical bills (both in and out of the hospital). For help with your specific concerns, you may want to talk with your employer’s benefits department, an independent professional advisor, or contact MIDʼs Consumer Services Division.

Purchasing Health Insurance

Purchasing health insurance is a very important decision. Many tend to base their entire insurance purchasing decision on the premium amount. As well as obtaining a good value, it is also vitally important that you deal with a company that is financially stable.

As the Health Insurance marketplace changes due to Healthcare Reform, understanding the health insurance you are purchasing is more important than ever.

Types of Insurance

There are several different kinds of health insurance. Traditional insurance often is called a “fee for service” or “indemnity” plan. If you have traditional insurance, the insurer pays the bills after you receive the service. Managed care plans use your monthly payments to cover most of your medical expenses. Health Maintenance Organizations (HMOs) and Preferred Provider Organizations (PPOs) are the most common managed care organizations.

Managed care plans provide health care in a more structured way than traditional insurance. Managed care plans encourage and in some cases require consumers to use doctors and hospitals that are part of a network. In both traditional insurance and managed care plans, consumers may share the cost of a service. This cost sharing is often called a co-payment, co-insurance or deductible.

Many different terms are used in discussing health insurance. “Covered persons” or “enrollees” are individuals who are enrolled in a health insurance plan. “Providers” are doctors, hospitals, pharmacies, labs, urgent care facilities and other health care facilities and professionals.

Disclosure Requirements

Whether you are considering enrolling in a traditional insurance plan or managed care plan, you should know your legal rights. Mississippi law requires all insurers to clearly and truthfully disclose the following information in their insurance policies:

  • A complete list of items and services that the health care plan pays for.
  • A complete list of items and services that the health care plan does not pay for (exclusions and limitations).
  • Any situations where the plan may not pay for all of your medical care (exceptions, reductions and limitations).
  • How long you may have to wait before the policy covers recent health problems (pre-existing condition exclusion period).
  • How the policy may be renewed;
  • How the policy may be canceled;
  • How the policy may be terminated;

A health plan may refuse to pay for health care services that relate to a health condition you had before joining your health plan. This is called a “pre-existing condition exclusion period”. State laws limit how long preexisting condition exclusion periods can be for individual and group health plans.

  • If you have a group health plan, a pre-existing condition is a health condition for which medical advice, diagnosis, care or treatment was recommended or received within 6 months of joining a plan. Your plan may refuse to pay for services related to your pre-existing condition for 12 months.
  • If you have an individual plan, a pre-existing condition is a health condition for which medical advice, diagnosis, care or treatment was recommended or received within 12 months of joining your plan. Your plan may refuse to pay for services related to your pre-existing condition for 12 months.

You may not have to serve a pre-existing condition exclusion period if you are able to get credit for your health care coverage you had before you joined your new plan. This is called “creditable coverage” and generally applies to group insurance. Ask your plan for more information. Your health insurer must renew your plan if you want to renew it. The insurer cannot cancel your policy unless it pulls out of the Mississippi market entirely, or you commit fraud or abuse or you do not pay your premiums.

Complaint Procedures

All health care plans must have written procedures for receiving and resolving complaints. These are often called grievance procedures. Grievance procedures must be consistent with state law requirements.

If your health insurer has refused to pay for health care services that you have received or want to receive, you have the right to know the exact contractual, medical or other reason why.

If you have a complaint about a health insurer or an agent, please refer to our File a Complaint Page. MID keeps track of the complaints that are filed. However, remember that when you are comparing companies and asking for the number of complaints that have been filed against a company, you must be aware that generally the company with the most policies in force will have more complaints than companies that only have a few policies in place.

Managed Care Plans

Here are some useful tips about managed care plans:

  • Every managed care plan must have enough providers so that you can get the care you need without unreasonable delay.
  • Every managed care plan must file a description of its network of providers and how it makes sure the network can provide health care services without unreasonable delay.
  • Sometimes, a doctor, hospital, or other health care facility leaves a managed care planʼs network. When this happens, a managed care plan must notify you if you saw that provider on a regular basis.
  • As a covered person, you and your doctor have the right to a complete list of providers that are part of the managed care planʼs network. You must get this list when you enroll, re-enroll, or upon request.
  • Every managed care plan must keep close track of the quality of the health care services it provides.
  • Managed care plans should not use rewards or penalties that encourage less care than is medically necessary. If you want to know more about how your plan pays its providers, you should ask.
  • Your managed care plan should notify you if it refuses to pay for a health care service based on a decision that is not medically necessary, efficient, effective or appropriate. The notice should include the main reasons for the denial and instructions on how to appeal.
  • Every managed care plan should follow certain procedures if it determines that a health care service was not medically necessary, efficient, effective or appropriate. The procedures must be fully described in the certificate of coverage or member handbook.

Shopping for Health Insurance

When shopping for health insurance it is important to make sure that you are buying the health care plan you want and can afford. You should make a list of your needs to compare with the benefits offered by a plan you are considering. You should compare plans to find out why one is cheaper than another. Listed below are some questions you should ask when shopping for health insurance:

Questions About Coverage

  • What does the plan pay for and not pay for?
  • Will the plan pay for preventative care, immunizations, well-baby care, substance abuse, organ transplants, vision care, dental care, infertility treatment, or durable medical equipment?
  • Will the plan pay for any prescriptions? If it pays for some, will it pay for all prescriptions?
  • Does the plan have mental health benefits?
  • Will the plan pay for long term physical therapy?

Not all plans cover all of the benefits listed above. Be sure to ask about benefits.

Questions About Premiums

  • Do rates increase as you age?
  • How often can rates be changed?
  • How much do you have to pay when you receive health care services (co-payments and deductibles)?
  • Are there any limits on how much you must pay for health care services you receive (out of pocket maximums)?
  • Are there any limits on the number of times you may receive a service (lifetime maximums or annual benefit caps)?

Questions About Providers

  • What are the restrictions on the use of providers or services under the plan?
  • Does the health plan require you to see providers in their network?
  • Does the health plan pay for you to see a doctor or use a hospital outside the network? Are the network providers conveniently located?
  • Is the doctor you want to see in the network accepting new patients?
  • What do you have to do to see a specialist?
  • How easy is it to get an appointment when you need one?

Questions About Customer Service

  • Has the company had an unusually high number of consumer complaints?
  • What happens when you call the companyʼs consumer complaint number?
  • How long does it take to reach a real person?

Lowering Your Health Insurance Premiums

  • Married couples in situations where both spouses are offered health insurance through their jobs should compare the coverage and costs (premiums, co-pays and deductibles) to determine which policy is best for the family.
  • Always stay in-network when possible, making sure to get referrals and pre-certifications as required by the plan.
  • Keep all receipts for medical services, whether in- or out-of-network. In the event you exceed your deductible, you may qualify to take a tax deduction for out-of-pocket medical bills.
  • Consider opening a Flexible Spending Account (FSA), if your employer offers one, which allows you to set aside pre-tax dollars for out-of-pocket medical expenses.

Health Insurance Tips for Different Life Stages

The NAIC’s consumer web site, Insure U, explains the different types of health insurance and gives focused tips to consumers based on their likely needs in different life stages. For example:

  • Young singles who may not yet have a full-time job that offers health benefits should be aware that in a growing number of states, single adult dependents may be able to continue to get health coverage for an extended period (ranging from 25 to 30 years old) under their parents’ health insurance policies even if they are no longer full time students. They should check with their state insurance department. In addition, some colleges also offer graduates interim coverage for a limited time. Another option: young people who can’t afford the health insurance offered by their employers should consider a lower cost, high-deductible medical plan to cover catastrophic medical costs.
  • Young couples expecting a child should make sure they register their newborn with their health insurance provider within the deadline required. They should also review their health plan to see whether prenatal and neo-natal screening and tests, prenatal vitamins, delivery costs (Cesarean and traditional) and what level of pediatric care are covered.
  • Established families with children should consider Flexible Spending Accounts if available to help pay for common childhood medical problems such as allergy tests, braces and replacements for lost eyeglasses, retainers and the like, which are often not covered by basic health insurance. All workers who lose or change jobs should know their rights to continue their health coverage under COBRA for up to 18 months.
  • Empty nesters/seniors who are under 65 and no longer employed, but whose COBRA benefits have run out, should research high deductible medical plans. At this life stage, consumers may want to evaluate whether they still need disability insurance. Many will want to decide whether long-term care insurance makes sense for them (e.g., will they be able to afford the premiums into old age, when most need to use such coverage).

Getting Assistance From The Mississippi Insurance Department (MID)

If we can be of assistance, please see the Request Assistance Page for information on how to contact us.