Why You Need to Understand Your Health Insurance Coverage:
Health plans cover treatment for injury or illness. Your health plan may not cover all of the health care services that you may need. For example, there may be limits on the number of visits for physical therapy or the number of days covered in a skilled nursing facility. Even if your doctor says you still need these services, if your health plan has a limit, it will not pay for the treatment beyond the limit.
You can avoid unexpected costs for health services that are not covered by your health plan by becoming familiar with the specifics of your health insurance plan and planning a budget. When planning a budget, make sure to consider premium payments, co-payments and any charges that will not be covered by your insurance, including amounts above your policy limit.
How You Can Learn More about Your Health Insurance Coverage:
The best way to make sure that you know what is covered by your plan is to carefully read your policy and ask your insurance company, insurance producer (also known as an insurance agent or broker) to explain anything that you do not understand. Your health plan is a contract that covers only specified services and supplies. If you or a family member needs treatment, you should look at the schedule of benefits in your policy to see if limits apply or contact your insurance company or insurance producer.
What is Custodial Care and is it Covered by Most Health Insurance Plans?
Custodial care can be provided in either a nursing home or at home, and includes daily activities such as bathing, dressing, eating etc. These services can be provided by someone that does not have medical training. Custodial care is generally not covered by health insurance.
Other options are available to pay for custodial care including long-term care insurance. For more information on these options, see our Frequently Asked Questions on long-term care, talk with a trusted insurance producer or visit www.longtermcare.gov
How Can You Appeal When Your Insurance Company Denies Coverage?
Your health plan may fully or partially deny a pre-authorization request or a claim for coverage if services are not covered by your plan or if it believes services are not medically necessary. For example, your insurance company may say that care is custodial but you think it is medically necessary. If you believe your request for pre-authorization or claim has been wrongly denied, you can file an appeal with your health plan. The instructions on how to file an appeal will be in your policy, and may also be in the Explanation of Benefits (EOB) letter or a Summary of Benefits and Coverage.
If your plan is subject to Maryland law, you may also be able to file a complaint with the Maryland Insurance Administration (MIA) by calling 410-468-2340 or toll free at 1-800-492-6116. Generally, you must appeal the decision through your health plan’s appeal process before filing a complaint with the MIA. But in some situations, you may be able to file a complaint with the MIA even if you have not completed your health plan’s appeals process. To learn more, go to: http://insurance.maryland.gov/Consumer/Pages/FileAComplaint.aspx#Download%20Forms%20to%20be%20Completed%20by%20Hand
If your health plan is not subject to Maryland law, you may still have the right to an external review of the health plan’s decision. You should read your policy for instructions on how to request this, or contact the HEAU for help in filing the request.
(Updated January 11, 2017)