Medical Insurance
Selecting medical insurance or a health plan is complicated. This guide is intended to give you an overview and should not be relied upon to make a final decision. You should consult with an employer’s health plan representative, or use a navigator, to review options and determine the best plan for yourself or loved one.
Medical insurance is available in various forms. Most insurance plans are considered “managed care plans” even though offered through private/commercial/employer or Medicaid plans. Managed care plans have contracts with health care providers and medical facilities to provide care for members at reduced costs. Usually members of these plans will pay some of the cost, in addition to a premium, in the form of copays, partial payments, or payments until a certain limit is reached.
Private or commercial insurance, more commonly known as employer-provided insurance, is offered through various health insurance, or health care, plans. Individuals are usually responsible for some or all of the insurance premiums, deductibles, co-pays and in the case of high-deductible plan, initial costs until a specified limit is reached. These plans are usually considered managed care plans.
State insurance marketplace plans are another option when an employer option is not available. Premiums may be offset or eliminated if a person’s income is under a certain limit. The plans offered work similar to employer plans in terms of deductibles, copays and high-deductible fees. These plans are often offered as managed care plans.
Medicaid plans are available depending on a person’s eligibility and may cover adults or children. The children’s plan in NYS is called Child Health plus.
Medicare is available to individuals age 65 or over. It is also available those who have a disability, including a mental illness, if a person meets eligibility requirements.
NYS Health Plan Marketplace
You can sign up for a new plan on the New York State of Health Official Health Plan Marketplace (Marketplace) during the open enrollment period or when your current plan year ends. The open enrollment period usually begins in November and ends in December. Children and adults who may qualify for Medicaid may apply for insurance on the Marketplace at any time of the year.
You can determine your eligibility, compare insurance plans and check your eligibility for tax credits by going online to: New York State of Health website at www.nystateofhealth.ny.gov.
Plans offered through the Marketplace must conform to provisions provided for by the Affordable Care Act. Plans purchased outside of the Marketplace, however, are not required to, and therefore may not comply with, all provisions of the law. These plans are said to be grandfathered and may not provide you with the same protections as the Marketplace plans. For example, your plan may place annual or lifetime dollar limits on benefits or not cover pre-existing conditions. It is important to check whether the plan you are considering buying is grandfathered. For more information about the Marketplace, please go to www.hhs.gov/healthcare/insurance/.
For more detailed information regarding protection for health insurance purchasers, click on www.hhs.gov/healthcare/rights. If you have any concerns or questions about your coverage going forward, contact your insurer directly.
Applying through Marketplace
The following resources will provide assistance in using the Marketplace to choose the best health insurance plan for you, taking into account your desired providers, your essential medications, your income level and family size.
- Help Line 855-355-5777;(TTY) 800-662-1220
- In-Person Assister (IPA) or Navigator. This personal assistance is free and is not tied to a specific insurance company. NYS provides training and credentialing for these individuals, who are knowledgeable about health insurance options and provide help in the application process, policy renewal, and obtaining financial assistance for insurance premiums. Several organizations offer IPA/Navigator services in a variety of languages. Services are by appointment and are offered at a variety of locations. When you call for an appointment, you will be told what documents you need and what locations are available.
The agencies with IPA/Navigator services and their respective areas are:
Healthy Community Alliance Inc., Erie and Cattaraugus Co. 716-532-1010
Kaleida Health, Erie County and N. Tonawanda 716-859-8979
Neighborhood Legal Services 716-847-0650
Erie, Chautauqua, Genesee, Niagara, Orleans, and Wyoming Co.
Niagara Falls Memorial Medical Center, Niagara County. 716-278-4264
Public Policy and Education Fund, Erie and Niagara Co. 716-364-0028
- Brokers. Agents for insurance companies who are paid a commission to sell specific insurance products. Links are available on the nystateof health.com under “Need Help?”
Renewals of policies obtained through the Marketplace are not automatic. Your plan, its network, its deductibles and copays and its drug formulary may change. If you do not renew, the federal law requires that you be assigned a plan of lesser cost if your premium would otherwise go up. Since premiums have continually increased in the past, you need to go to the Marketplace each year to evaluate the policies and select the best one.
Medicaid/Child Health Plus
Application for Medicaid and Child Health Plus is included in the Insurance Marketplace (855-355-5777). In some cases, individuals may have to go to the Erie County Department of Social Services(ECDSS). Applications may also be filed at a Managed Care Organization, through the Navigators and Certified Application Counselors, or by calling the Medicaid Hotline (800-541-2831).
In order to prepare for the application and to assure that you have the materials that will be required, go to the NYS Health Department web site at: www.health.ny.gov/health_care/. This site provides information about eligibility, application materials, special circumstances which qualify applicants for help with insurance premiums, Medicare premiums or COBRA costs and other helpful information.
Once an individual qualifies for Medicaid, there is usually an annual renewal. Medicaid mail cannot be forwarded by the Post Office, so recipients must inform ECDSS Medicaid of an address change. It is helpful to let the treatment provider know the Medicaid renewal date as providers such as social workers, counselors, health home case managers, and others often have an investment in assuring that there is no break in coverage and have access to ECDSS to facilitate the renewal even if the recipient is not cooperating in the application or renewal process. Peer services which provide benefits services or skills training may also help recipients with the renewal process.
These programs cover all medical expenses and prescriptions.
Medicare Plans
Medicare provides medical insurance and prescription coverage for individuals who are disabled or who are age 65 and above. Information is sent to individuals who receive Social Security.
Medicare has 3 parts:
- Medicare Part A Hospitalization Coverage
- Medicare Part B Supplemental Medical Coverage
- Medicare Part D Prescription Coverage (Additional information on this coverage is provided in this guide under “Paying for Prescriptions”.)
Information on Medicare coverage is available by calling 1-800-Medicare or www.medicare.gov. Your local librarian can be an excellent resource for using the computer to obtain information. You must have your Medicare ID number if you want to track personal claims information or evaluate various plans in your local area.
Timothy’s Law was enacted in 2007 in NYS, requires employer-based commercial health insurers to cover, minimally, 30 days of hospitalization and 20 outpatient visits. They must also have deductibles, copayments and coinsurance which are no greater than those applied to other illnesses or services. Large employers (50 or more) must also include full parity coverage for treatment of “biologically based” mental illness, which is defined as schizophrenia, psychotic disorders, major depression, bipolar disorder, obsessive compulsive disorder and eating disorders.
Managed Care Plans
Managed care plans are the most common types of insurance plans and are offered by commercial (employer) plans or publicly funded plans (e.g., NYS Marketplace, Medicare, Medicaid). Managed care plans vary by type of benefits and costs. They have different premiums, co-pays, high deductibles, annual limits on certain services and drug co-pays. They may have different networks of providers, formularies for medications (which vary both in specific drugs covered and level of co-pay) and prior approval requirements for some or all specialized care. Thus it is important to understand the product differences. Individuals should make sure that their preferred providers, both medical and behavioral health, are included in their plan’s provider network.
In most cases, enrollment in a plan will be for one year or until the next open enrollment date. Care should be taken in choosing a plan. It is also helpful to talk to your preferred providers of services and your pharmacist as these professionals may have experience with plans you are considering. They may also inform you if they are not included in the provider network of the plans you are considering.
Greater coverage with lower copays and/or deductibles will result in higher premiums and vice versa. Thus it is important to understand the product differences. Individuals should make sure that their preferred providers, both medical and behavioral health, are included in their plan’s provider network.
The limits on visits stated in the Plan documents and booklets are maximum limits, i.e., 20 outpatient mental health visits. The provider of the service must obtain prior approval to use those visits. Therefore, it is useful to ask your mental health provider about preferred plans since this provider may have more success obtaining approvals from one company than another. Certain mental health services such as Day Treatment, Continuing Day Treatment (CDT), Intensive Psychiatric Rehabilitation Treatment (IPRT), Case Management/Intensive Case Management, Assertive Community Treatment (ACT), and PROS (Personalized Recovery Oriented Services) are not covered by a private insurance or managed care plan. They are covered by a sliding fee scale if the individual does not have Medicaid.
Medications covered by your plan are listed in the Drug Formulary. See the section on Medications for more information.
Managed Care Rights & Appeals
Enrollees of managed care plans have rights related to the care provided as well as the associated costs and processes. This information is included in the annual mailing from your insurance company. Much of it will also be available on the web page for your company. Some information such as network providers, covered medications and costs and copays are included in the Marketplace for enrolling in an Affordable Care Act Plan.
For detailed information about your rights please visit https://www. health.ny.gov/health_care/managed_care/billofrights/bill.htm
If your treatment or medication is not approved
When your health plan denies treatment, it must give you notice of your right to have the decision reviewed. Your health plan must have staff available during normal business hours to accept your grievance. Decisions about current or future treatment must be made within one business day of receipt of the necessary information.
Internal Appeal Process
In New York, health plans must respond to appeals about denial of care within a specified time frame. The original appeal is to the plan and is referred to as the internal appeal. The plan documents define this process or the individual may call the Plan to obtain information on this process. If the internal appeal timeframe (2 business days for expedited appeals and 60 days for standard appeals) is not met by the plan, the service must be covered by the plan making an external appeal unnecessary. If the internal appeal is denied because the Plan considers the service not medically necessary, specifically excluded from coverage, or experimental or investigational, you may apply for an external appeal.
“Medically necessary” service is partially or fully determined by what the provider of the service says to the health plan about why the service is needed. The plan documents usually state what the definition of medical necessity is for this plan. Criteria focus on “reasonable and appropriate” for diagnosis and treatment of the condition which means there is evidence that the intervention works and is working, i.e., improving functioning of this individual. Regardless of how medically necessary a service is, it will not be paid for if the plan does not list it as a covered service, or, specifically excludes it.
External Appeal Process
If you are not satisfied with the decision of the Internal Appeal, you should contact:
New York Insurance Department Hotline 800-400-8882
Voicemail system 800-342-3736
www.externalappealquestions@dfs.ny.gov
Who may appeal:
You, your provider (with consent) or your authorized representative
What you may appeal:
Denials of coverage for services which the health plan determines are not necessary or are experimental or investigational. You cannot appeal services not covered by the plan and/or specifically excluded.
When you may appeal:
After denial for coverage has been appealed through the first level of the health plan’s internal process or the plan and patient jointly agree to waive the internal appeal, you must file within 45 days from receipt of the first denial or a letter from the health plan waiving the internal appeal.
What to send:
Completed application (a physician’s statement is required for experimental/investigational appeals) and a copy of the adverse determination letter or a letter from the health plan waiving the appeal.
What you must pay:
Up to $50 (the fee is waived under certain conditions). The fee is returned to the patient if the health plan denial is ultimately overturned.
What will happen:
The NYS Insurance Department will review the appeal request within 5 business days and assign the request to an external review agent if the request is eligible and complete. The external review agent will have a medical expert/s review the appeal and determine the outcome in 30 days. In urgent situations, an expedited appeal will be reviewed by the insurance department within 24 hours and the outcome determined by the external review agent within 3 days.
You may appeal any decision. Appeals should be accepted by telephone or in writing. Your appeal must be filed within 45 days after you receive a decision. Your appeal must be acknowledged in writing within 15 days, and a final determination by the plan must be made within 60 days after all necessary information is received.
Expedited Appeal
You are entitled to a fast appeal when you are denied continued treatment prescribed by your practitioner. A clinical peer reviewer at your health plan should be available within one business day of receipt of your notice of an expedited appeal. Expedited appeals must be determined within two business days of receipt of necessary information. If you are not satisfied with the result after an expedited appeal, you may further appeal through the standard appeal process.
