NAVIGATING PRIVATE HEALTH INSURANCE
Organization
and persistence are the keys to success!
Supplies needed: Communication log next to your phone, 3-ring binder, 3-hole punch
I. COMMERCIAL OR SELF-FUNDED
A. Distinction determines whether state or federal law applies
1. Commercial - Colorado State Law applies
a. Division of Insurance (DOI) has jurisdiction
b. Mandated benefits are decided in the state legislature
2. Self-funded (same as ERISA)
a. Department of Labor (DOL) has jurisdiction
b. State mandates are not required
B. How to find out whether your plan is a commercial or self-funded plan
1. Ask your employer - Human Resources Manager/Department
2. Look at the plan – particularly under Denials/Appeals/Complaints
a. Commercial plans have external reviews referred to in the appeals process section
b. Look for language re: DOI or ERISA
C. Why knowing this difference is important
1. State Mandates related to autism spectrum disorders (www.dora.state.co.us/insurance)
a. Children’s Therapy (Colo. Revised Statutes (C.R.S.6) Section 10-16-104(1.7))
Provides 20/20/20 sessions of OT/PT/Speech to age 5(congenital defects)
b. Autism is a medical, not a mental condition (C.R.S.10-16-104 (5))
c. Parity Law (C.R.S. 10-16-104(5.5) Requires group plans to provide coverage for treatment of six biologically based mental illnesses-as per physical illness (schizophrenia, schizoaffective disorder, bipolar affective disorder, major depressive disorder, specific obsessive-compulsive disorder, panic disorder)
d. Network Adequacy (C.R.S. 10-16-704(1)) Managed care plans must maintain adequate network in numbers and providers to assure covered benefits accessible without delay
2. Appeals Process-State Law Requirements
a. Mandated procedures and notification requirements
b. Two levels of appeal plus external review
c. Jurisdiction-DOI versus Department of Labor
II. READ YOUR CONTRACT
A. Benefits or Policy Manual is your contract
1. Read about Covered Benefits, Exclusions, Appeals Process; using Glossary of Terms
2. Understand and follow non-compliance with terms of contract (including pre-authorization)
B. Open Enrollment
Read disclosures and do “comparison shopping” about benefits/exclusions as well as premiums
III. PREAUTHORIZATION
A. Insurance may not pay if pre-authorization is not obtained
B. Do not rely solely on physician’s staff—it isn’t possible for them to know all the ins and outs of your contract (and every other patient’s) —be proactive and confirm with your health plan
C. Referrals—ascertain that referral is complete or insurance may not pay the benefit
IV. COVERED BENEFITS AND MEDICAL NECESSITY (See Denials and Appeal Sections)
For a treatment to be covered, two criteria must be met
1. It must be a covered benefit per your contract or not specifically excluded
2. It must be medically necessary*
*If challenged, garner letters of support from all professionals involved (including physician orders with diagnostic codes, specific problems and related goals with specific orders)
V. A DENIAL MAY MEAN IT IS TIME TO APPEAL
A. “No” is not always the final answer
B. Denial based on “medical necessity”
1. Commercial health plans required by state law to:
a. Notify contract holder (not the provider) in writing
b. Give specific medical reasons with signature of physician (“not a covered benefit” is not a specific medical reason-demand a reason-it’s your right to know!)
c. Advise about appeal rights
2. Provide contract language to your physicians and therapists to help them write letters of medical necessity (It may be helpful to your providers to draft your own letter for their review)
3. Write a cover letter for the appeal, referring to and attaching letters of support and a copy of the denial letter
4. Send by certified mail and follow up with a phone call to acknowledge receipt
5. Do not allow the physician’s office to do the appeal for you—it is your contract
C. Denial based on contract exclusion or “not a covered benefit”
1. Read your policy language to see if this contention by the plan is subjective or clear
2. If there is ambiguity, uncertainty, or conflict as to coverage, the policy should be construed in favor
of the insured
3. If you are in a self-insured plan, discuss an expansion of benefits with your employer
4. If it is true, base the appeal on cost/benefit to the plan and/or mitigation of secondary disability
VI. COMMUNICATION LOG
Keep a log by your phone
1. Record date, times, names and content of every call with the insurer
2. Request every approval or denial in writing from them and if no response, write to them and copy the DOI or the DOL
VII. WRITING THE LETTER OF APPEAL
A. Provide your appeal in writing – tone of the letter should be assertive and factual, not aggressive and emotional
1. If it is urgent, request an expedited appeal by phone and follow-up in writing
2. Provide a brief background of your case
3. Cite relevant and helpful language from your contract (with page numbers)
a. Demonstrate that the treatment is a covered benefit (photocopy of page)
1. If treatment is a benefit exclusion, state law does not require the same appeal procedures as medical necessity, but you have the right to challenge the decision (see 2. below)
2. Argue why the health plan should make an exception for your family- your best argument is “cost/benefit” or mitigation of “secondary disability”
b. Demonstrate that the treatment is medically necessary
1. Include and refer to letters provided by physicians, therapists, specialists
2. Include second opinions, medical literature, safety and cost issues—any information helpful to your case
B. Commercial insurance provides three levels of appeal, including a face-to-face meeting and an independent external review. Do not give up if the first appeal does not result in a reversal of the denial.
C. The appeals process for self-funded plans is in the contract (plan document).
Consider asking your employer to assist with the appeal
VIII. HELPFUL HINTS
A. Establish relationships—ask for supervisors, send photos of the child, be respectful
B. Always manage your plan by reading notices; asking if the physician is still in the network
C. Treat every year as a new year—establish that benefits won through appeal are still available
D. Your physician is your best advocate—support him/her with information about your contract
E. Ask
for help: Family Voices –
If you have a plan
regulated by the State of
1560
Broadway,
(303)
894-7490/toll free 1-800-930-3745
www.dora.state.co.us/insurance
For information and assistance with self insured plans, contact:
(816) 426-5131