What is an Insurance Election Period?

Because of the nature of insurance plans, you cannot simply enroll or unenroll whenever you wish. Every insurance plan as an annual period called the Open Enrollment Period where you may add, drop, or change the plan without penalty. Generally, if you receive your insurance through your employer, you don't have to do anything to maintain your enrollment--it will continue automatically, but if you would like to change or tier level, switch from HMO to PPO, or unenroll entirely, the Open Enrollment Period is your annual opportunity. Open Enrollment also applies to those who are enrolled in Medicare, Medicaid, or TriCare plans.

HCA or ObamaCare has changed the rules for insurance enrollment

But you do not always have to wait for Open Enrollment to change your insurance plans. Legally, there are a series of qualifying life events that will provide a time frame--generally 30 to 60 days--in order to make any necessary changes without penalty for adding or dropping a plan. These qualifying life changes include:

Marriage or Divorce
Gain or Loss of Employment
Birth of a Child
Turning 65
Losing coverage from the loss of spouse or domestic partner
Loss or change of residence
Leaving Incarceration
Starting or Ending AmeriCorps Service

If you have had a sudden life change, you may qualify for benefits or insurance coverage that you did not previously qualify for. Remember, if you are eligible for a health insurance plan and you choose not to enroll in one, you may be taxed for failing to have coverage. Be sure you understand your eligibility and requirements when you've had a qualifying life event.

Comments

What is a Third Party Administrator?

You likely know the name of your private insurance carrier and you may even know the name of your employer's worker's compensation insurance carrier--but what you may not know is that these insurance carriers have little to do with your actual claims. Instead of doing the back-office work themselves, they contract with Third Party Administrators, or TPAs. TPAs are responsible for a wide number of tasks. They may conduct Utilization Reviews for medication and medical procedures and issues authorizations or denials. They may handle pharmacy benefits, or contract directly with the pharmacy benefit managers (PBMS) that process the pharmacy claims. They handle all billing for medical providers, and pay those providers based on contractual agreements. The TPA may have complete control over every financial aspect of your private insurance or worker's compensation claim. Sedgwick or United Healthcare may be your insurance carrier in name only. Insurance carriers contract with ...

In or Out of Network? Primary Care of Specialist? HMO or PPO?

Throughout your life, you will change insurance carriers many times. Sometimes you lose or gain eligibility due to a career change. You may age into Medicare eligibility, you may marry or divorce, may choose to join a plan on the Healthcare Exchange, or may become disabled and eligible for your state's Medicaid or Social Security benefits. Depending on the type of insurance, you may be able to change your plan every year, or you may have to wait until you have a qualifying life event. Each time your benefits change, you are faced with the same series of questions and considerations. Is your regular physician in your new network? Do you need to get a new referral to continue to see your allergist or cardiologist? Will your deductible be higher or lower? Are your medications still covered? What is your new copay for regular visits? Can you go to the emergency room if if it's necessary? First it's necessary to understand the difference between an in-network provider (INN)...

Common Insurance Terms

Pharmacy Benefit Manager (PBM ): Third party companies such as OptumRX, ExpressScripts, and CVS Scripts that contract with insurance carriers and coordinate with pharmacies to process pharmacy benefit claims. The Big Three process over 70% of pharmacy insurance claims in the United States and they they are not obligated to ensuring patient care or maintaining the standard of care. They promise to reduce costs to insurance carriers and profit from minimizing care to patients. Third Party Administrators (TPA) : Third party companies that are contracted with insurance carriers to administer claims, including adjust and adjudicate, guarantee payment, utilization reviews of medical and pharmacy authorizations, contract with providers, and accept or deny liability. Claims: Payment requests from medical providers or pharmacies submitted to the responsible party. Responsible Party : The responsible party for a claim is the person or entity legally obligated to provide payment...

Patient Services Solutions

Search This Blog