Health Insurance and Your Rights

Health insurance is critical for your livelihood. It can ease the financial stress of expensive medical care. It can also relieve the emotional strain of thinking about caring for your loved one. But navigating deductibles, pre-authorizations, co-payments, and other confusing jargon can be exhausting. It can get more stressful when your own insurance company denies your claims.

This article provides an overview of health insurance laws and procedures, which vary by state. If you’re in a dispute with a health insurance company, contact a local and experienced health insurance lawyer, who can give you legal advice and represent you and your interests in a legal action.

What Is Health Insurance?

Health insurance laws determine patient rights, health care privacy, and health insurance claims. They also cover federally created insurance programs like Medicaid and Medicare.

Medical insurance is a contract with a health insurance provider to get benefits in exchange for paying insurance premiums. Health insurance law typically breaks down into three categories:

• The insurance business: Company policies, insurance coverage, and ethics
• Health insurance policy content: Policy language and what goes into insurance policies
• How to handle insurance disputes and claims: Procedures for who handles health insurance claim denials and the appeals process

As the policyholder, your insurance policy is actually an insurance contract between you and the provider. When your insurance provider refuses to honor a claim, they could be breaking that contract. But not every denial is a breach of contract. A lawyer can help you understand how to handle discrepancies in medical bill payments, qualifications, or when you receive your benefits.

Government Agencies and Programs

Both state and federal governments offer various health care and insurance benefits. Below are major insurance and health care agencies and programs.

COBRA

COBRA refers to the Consolidated Omnibus Budget Reconciliation Act. Under COBRA, your employer must provide continued group health coverage for a limited time after you leave a job. However, you will be responsible for paying the entire cost of the premium.

COBRA applies to private, state, or local government employers with 20 or more employees that offer group health plans. COBRA coverage can last up to 18 or 36 months after you leave.

Medicare vs. Medicaid

Medicare is a federal program that pays for medical care for people of retirement age, people with disabilities, and people with other qualifying conditions. Medicaid gives federal health coverage to people with low income who can’t afford medical care.

Several differences set Medicare apart from Medicaid. Some people are eligible to receive benefits from both. The differences include:

• Medicare is federally administered, and its eligibility requirements and benefits are more standard than Medicaid’s. Medicaid is state-administered, so its offerings and requirements vary.
• Medicare is available to every eligible person who has paid into the program over time through payroll taxes. Medicaid doesn’t require beneficiaries to pay for services. But it’s only available to people with low income.
• Medicaid can have flexible benefits, depending on the state. Medicare has a definitive plan structure covering only certain benefits.

The Affordable Care Act

The Affordable Care Act (ACA) is a law passed in 2010. Also known as Obamacare, this program makes health insurance plans available to more people. Before the ACA, many people couldn’t afford health insurance. Others could be denied coverage for basic needs. Some people were also denied because of preexisting health conditions, like asthma or diabetes. The ACA is important because:

• It covers more people: The ACA allowed millions of people to get health insurance by offering financial help to make insurance more affordable. The ACA also expanded Medicaid in many states.
• It covers preexisting conditions: The ACA stopped insurance companies from denying coverage because of pre-existing conditions. This means everyone can get insurance, even if they were sick before they applied.
• It covers essential benefits: The ACA requires health plans to cover essential health benefits. This includes doctor visits, hospital stays, mental health services, and maternity care.
• It covers preventive care: The law includes free preventive care so people can get yearly physicals, vaccines, and screenings to stay healthy without extra costs.

ERISA

The Employee Retirement Income Security Act of 1974 (ERISA) sets the minimum standards for employer benefit plans. This includes retirement plans and employer health insurance plans. ERISA regulates access to plans, benefit plan management, and employee rights. 

HIPAA

The Health Insurance Portability and Accountability Act (HIPAA) is a federal law passed in 1996. HIPAA protects sensitive health information from disclosure without your consent. HIPAA ensures that anyone accessing your health information will keep it private and secure. It sets rules for handling health data by health care providers, insurance companies, and other entities.

Get Legal Help

Health care and insurance laws and rules are complex. It can be frustrating and time-consuming when your insurance company denies medical treatment and you don’t know why. Consult with a qualified health insurance lawyer to help resolve any legal issues with your health insurance coverage.