Insurance issues

Is it covered?

Decisions regarding coverage for a medical service or procedure are generally governed by the language of the insurance policy. These policies are developed by the insurance companies and act like a legal contract between the insurance company and the patient. Insurance policies usually, but not always, cover all “medically necessary” services and procedures. These insurance policies, however, contain many exceptions to exclude those services and procedures that are determined to be experimental, elective, inappropriate, or otherwise medically unnecessary. Some, but not all, policies will specifically exclude coverage for a particular condition. 

Most patients do not negotiate their insurance policies with the insurance company, which makes it difficult to know whether a service or procedure is covered. Most insurance companies allow customers to review their policies online or have a telephone hotline with customer service representatives who can assist you in determining whether a service or procedure is covered by your policy.

Under the Patient Protection and Affordable Care Act (PPACA), starting in 2014, insurance policies will be required to cover a package of “minimum essential benefits” which fall into 10 categories of benefits as follows:

  • Ambulatory patient services,
  • Emergency services,
  • Hospitalization,
  • Maternity and newborn care,
  • Mental health and substance abuse disorder services,
  • Prescription drugs,
  • Rehabilitative and habilitative services and devices,
  • Laboratory services,
  • Preventive and wellness services and chronic disease management, and
  • Pediatric services, including oral and vision care.

For more information on PPACA, go to: 

What can I do if coverage is denied for a particular claim?

A recent government study indicated that coverage denials are reversed on appeal approximately 40% of the time. Insurance companies deny claims for coverage for a variety of reasons, usually relating to billing errors or questions about a patient’s eligibility for a given service or procedure. It is important to find out why you are being denied coverage in your particular case. The first step in resolving a coverage dispute is for the insurance company to provide the patient and/or the patient’s treating physician with a written explanation for the coverage denial.

Many insurance policies have an appeal process which guides the process for patients and their families to follow when insurance coverage for a service or procedure is denied. Therefore, consulting your insurance policy is one of the first steps you should take when responding to a denial of coverage. Appeal forms may be available through the insurance company’s website and procedures to follow may also be contained in the Explanation of Benefits form (EOB) you receive following a service. There is often a time limit to how long a patient can wait to file an appeal, so do not delay!

Frequently appeal procedures require a patient to write a letter explaining why the service of procedure is medically necessary and appropriate for the patient’s condition. Insurance companies may also need medical records from a physician to support the position that a service or procedure should be covered or to dispute the insurance company’s reason for denying the claim.

If you feel that your insurance company acted improperly in denying your claim, you may file a complaint with the Pennsylvania Insurance Department or the Pennsylvania Attorney General’s Office: Insurance department main site Insurance department complaint form Attorney general main page Attorney general complaint form

Under PPACA, insurance companies will be required to provide detailed reasons for coverage denials and also provide patients with specific information regarding their appeal procedures. For more information on PPACA, go to: 

Can my premiums be raised?

A number of factors play a role in the rise of health insurance premiums. A patient should not expect that their insurance rates will rise immediately following a claim on his or her insurance policy. Nonetheless, insurance companies track patient medical data for all patients in a health plan and consider this medical data when negotiating policy renewals. Therefore, if a patient has an individual health insurance policy, it is more likely that his or her premiums will be increased in future policy years following a significant claim against the insurance policy. If a patient receives insurance through a group health plan, such as through the patient’s work, premiums will be increased or decreased each year based, in part, on the medical data reviewed for all of the group health plan’s participants. The greater the number of participants in a group health plan, the less likely that one patient’s benefit claims will affect premium rates. 

Portions of PPACA are designed to discourage employers from imposing drastic increases on their employee’s health insurance premiums and other out-of-pocket health care expenses, but such increases are not prohibited.  For more information on PPACA, go to:

Pre-existing conditions

A pre-existing condition is a medical condition that existed before someone applies for or enrolls in a new health insurance policy. It can be something as serious as heart disease, cancer, or diabetes, or as minor as allergies or a prior sports-related injury.  In the past, some insurance policies limited, or even denied, coverage for conditions existing before a patient obtained the insurance policy. 

Under HIPAA, an insurance policy is only allowed to look back six months for a condition that was present before the start of coverage in an insurance policy. If you have a pre-existing condition that can be excluded from your insurance policy, HIPAA provides a limit to the length of time that pre-existing condition exclusion period that can be applied. This time period is 12 months in most cases, although for some individuals with prior health insurance coverage, this time limit can be decreased even further.  For more information on HIPAA, go to:

Under PPACA, insurance companies cannot exclude children with preexisting conditions from being covered by their family’s insurance policy. Insurance companies will not be able to exclude adults with pre-existing conditions from being covered by his or her insurance policy after January 1, 2014. For more information on PPACA, go to:

Life insurance

Life insurance is often purchased to protect your loved ones financially after your death. It is intended to allow your dependents to maintain their current standard of living in the event that you die. However, because families undergoing a medical crisis often encounter many unexpected expenses, such as the cost of medical services that are not covered by health insurance or the cost of providing for long term care, there are times when an individual needs to access the cash value of the policy prior to their death. If you have a life insurance policy that is the type that has accumulated a cash value over time, and you are in need of financial resources, you may be able to accelerate your policy’s benefits in order to pay for your medical costs and other expenses, or those of a family member. Often a policy will allow you to either cash your policy in early, or to take a loan against the policy. It is important to remember that if a loan is not repaid, the death benefit under the policy will be reduced, or even eliminated. Your options will vary greatly depending on the type of life insurance policy you have, as well as the terms specific to that policy. As such, you may wish to contact your insurance agent to discuss the options available to you pursuant to your life insurance policy.

IRA early withdrawal

If you have an Individual Retirement Account there are options for early withdrawal of funds to pay for things like health care and avoid costly penalties. These rules are very complex and you should consult a financial advisor or attorney before making any decisions to access retirement funds early. However, this may be one source of funds to help pay for care that is not covered under your health insurance. More information about early withdrawal of IRA funds can be accessed on the Internal Revenue website at: 

Long-term care insurance

Because long-term care services are generally not medical in nature, this care is often not covered by private health insurance policies. Additionally, Medicare and Medicaid may cover long term care only in certain situations. As a result, many individuals choose to purchase long-term care insurance. 

In Pennsylvania, long-term care insurance policies are required to offer what is considered to be comprehensive coverage. Specifically, these policies must cover skilled nursing care when ordered by a physician, intermediate care, custodial care, and home health care. Often long-term care policies provide a daily benefit dollar amount (such as $250 per day) and may provide coverage for a specific period of time, such as a year, or up to a lifetime. Additionally, it is important to know that long-term care policies sometimes impose a waiting period. This means you may need to be covered under the policy for a certain amount of time before you are eligible for benefits under the policy. You may find additional information about purchasing long-term care insurance in Pennsylvania at:

Additionally, the following links may provide useful information:– HHS’s National Clearinghouse for Long Term Care Information – HHS’s Administration on Aging, Office of Community Living Services and Support

PA Children's Health Insurance Program

If you do not have health insurance available through your employer, you can still obtain health insurance for your children through Pennsylvania’s CHIP program. CHIP stands for Children’s Health Insurance Program and is available to all Pennsylvania uninsured children that are not covered by Medicaid. There are no exclusions for pre-existing conditions under the CHIP program and you do not have to be low-income to qualify. The premium for health insurance provided through CHIP is determined by a sliding scale based on income. For many families it’s free, and for others, there is a low monthly premium. For more information and to apply for CHIP health insurance coverage, please go to:

No insurance?

While during an emergency you will be treated in the emergency department of a hospital regardless of whether you have health insurance coverage, most doctors and hospitals will not provide care to individuals in a non-emergency situation unless they are insured or can otherwise guarantee payment. In addition, as of January 1, 2014, the Patient Protection and Affordable Care Act (PPACA) requires that all Americans have health insurance of one form or another and makes access to health insurance more readily available than ever before through state and federal run exchanges. These exchanges give you access to a variety of different insurance options including Medicaid through either the Federal website, or through a number of state run exchange websites. In Pennsylvania, the Federal website is used to access options.

If you are not insured after March 31, 2014, you could face a fine in the form of a special tax applied to your federal tax return.

It is vital to obtain health insurance coverage in the event that you do not currently have coverage. The most common place you will access health care coverage is through an employer’s sponsored plan. All employers with more than 50 full time employees are now required to offer a group health insurance plan. In addition, with the PPACA passage in 2010, your employer’s plan, if it offers a family coverage option, must also offer coverage for your children up to age 26. While some group health plans will allow you to enroll in coverage at any point through the year, most have an annual open enrollment period, during which you may enroll in coverage. Additionally, if you have originally declined coverage due to the fact that you had other coverage, you may be eligible to enroll outside of the annual open enrollment period. This is known as “special enrollment.” If you lose the other coverage through loss of a job, or if you gain or become a dependent through marriage, birth, adoption, or placement for adoption, you may enroll in the plan outside of the open enrollment period. You must notify your employer within 30 days of the special enrollment event. If you need to wait until the next open enrollment period to gain coverage under an employer’s policy, you may wish to enroll in a short-term individual insurance policy in the interim. Short-term policies are intended to provide coverage for only a limited period of time.

Another avenue through which you used to be able to obtain coverage is through Pennsylvania’s high risk pool, known as Fair Care. This high-risk pool was a temporary solution established pursuant to federal health reform to provide coverage for adults with pre-existing conditions until 2014 when a host of additional reforms became effective. This program is now administered by the Pre-Existing Condition Insurance Plan (PCIP). Information regarding the plan can be accessed through the following website: 

Likewise, children may be eligible for CHIP. Additional information regarding eligibility for and enrollment in CHIP may be found at:

In Pennsylvania, the Blue Cross and Blue Shield Association companies have traditionally been considered to be the “insurers of last resort.” This means that even if you are sick, these companies must cover you in what is known as a guaranteed issue policy. This concept is changing with the guaranteed coverage required under the PPACA and insurance plans available under the Federal Exchange.

Finally, resources are available to direct you to the best options.  In Pennsylvania, the APPRISE health care insurance assistance program can help guide you and answer many questions beyond the scope of this document. To access the system go to: – APPRISE Health Insurance Counseling Services