Managing Your Insurance

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Published: 17th August 2015
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The Affordable Care Act has made the whole procedure of getting enrolled for health insurance to filing a claim transparent and easily accessible. It also held insurers accountable for the way they spend premium dollars and increase rates. It has introduced "Medical Loss Ratio" and "Rate Review" to help consumers find health insurance best suited to them. It has made getting and managing easier.

One can use Department of Insurance website to find a basic profile of insurance company or information about Medical Loss Ratio (MLR) and Rate Reviews. One need to have information about the name of your insurance company, or company's NAIC Number to know about Medical Loss Ratio (MLR) and Rate Reviews.

Insurers must use 80% to 85% of the premium dollars on health care costs and health care improvement activities. This is called Medical Loss Ratio. Insurers doing otherwise have to pay a refund to the policy holders. Health insurance companies also need to inform consumers when in case they are going to increase insurance rates for individual or small group policies by an average of 10% or more.

The affordable care act has improved manageability of health insurance in other ways too.

Insurance Rejection

From 2014, insurers can not reject coverage on basis of a disability or medical condition, or due to pregnancy. Right now some states do not charge high premium, reject insurance or exclude certain benefits due to existing health condition or disability. But most of them do. By 2014 it will change and pre existing condition will not be used to reject insurance. The New individual plans and all job-based plans are prohibited from denying insurance to children due to a pre-existing condition, including a disability.

People having pre-existing condition and uninsured for at least six months may qualify to get coverage under the Pre-Existing Condition Insurance Plan created under the Affordable Care Act. The act also prohibits insurers from denying coverage due to pregnancy. Right now most states deny coverage to pregnant women. But by 2014 under the Affordable Care Act this practice will abolish. Insurers will not be allowed to deny coverage or charge higher premium because of pregnancy or other health conditions. Till then pregnant woman can use Medicare or CHIP to get insurance coverage.

Right to Appealing Denials

The Affordable care act gives consumer a right to appeal if they are denied a health insurance claim. Insured individuals have right to both an internal and external appeal. After The Affordable Care Act they got the right of an independent third party review too.

Claimant can ask for an internal review of the denial by the insurer. Claimant has the right to information about internal appealing process and the insurer must provide it to him. Insurer needs to send the claimant a notice of the final decision including explanation of the outcome. Many cases which are denied by mistakes or on behalf of minor error are solved at this stage. Many health plans have several steps in the appeal process. In that case if the initial appeal is denied, one can file additional appeals.

If the internal review does not come out as satisfactory to the claimant, he can go for an external review. It could be done by state insurance department or an independent third party. If the insurer does not provide information about external review filing process, the claimant has right to ask for help from human resources department.

Consumer Help

Many states provide consumer help through Consumer Assistance Programs to help them through health insurance problems. They provide consumers direct help to solve the problems or questions about health coverage by phone and email. One can also use phone numbers, email addresses, and links to state's Department of Insurance as some states do not have any Consumer Assistance Programs.

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