Consumer information guide : the new nongroup health insurance plans in Massachusetts

18 Pages·1997·1.4 MB·English

by  Massachusetts. Division of Insurance

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Consumer Information Guide
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The Nongroup Health Insurance Plans
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Who
is Eligible?
When Can I Enroll in a Plan?
Can I Be Denied Coverage Because of My Medical History?
What About the Coverage I Already Have?
What Will Be Covered in the Nongroup Plans?
How Much
Will It Cost?
Are There Any Other Options?
Whom
Should I Call for Additional Information?
A. Paul Cellucci Linda Ruthardt
Governor Commissioner
of Insurance
October 1997
Disclaimer
The Division of Insurance does not sell, recommend, promote, nor endorse
any insurance product, company, or agent. The information in this guide is being
provided to assist consumers in making informed purchasing decisions. Every
effort has been made to ensure the accuracy of this information; however, some of
the information may be subject to correction. This guide will be updated
periodically.
Please note that this guide applies only to policies available for sale in
Massachusetts to individuals and families who are "eligible individuals" as
defined by law.
The passage of chapter 176M of the Massachusetts General Laws allows
Massachusetts residents who are not eligible for employer-based health coverage
to purchase nongroup health care insurance or coverage from any carrier offering
plans. Carriers offering this coverage will not be able to refuse any applicants
based on their health nor impose preexisting condition exclusions or waiting
periods. This publication is intended to
• explain your rights to purchase coverage under this new law;
• tell you which companies offer the new coverage;
• tell you how to contact health carriers for more information regarding
nongroup health coverage; and
• tell you what you need to know if your coverage may end in the future.
Who
is eligible?
You and your dependents are eligible for this coverage if:
• you are a Massachusetts resident;
• you do not have access to group health coverage through your workplace or
your spouse's workplace;
• you are not or are no longer eligible for continuation of group health coverage
COBRA
under or other continuation of coverage laws;
AND
• you are not enrolled in Medicare or Medicaid;
• you are not self-employed. (Under Massachusetts law, self-employed persons
are not eligible for nongroup health coverage because they may buy coverage
from any insurance carrier which offers coverage to small businesses.)
When
can I enroll in a plan?
You can apply for coverage each year during an annual two-month open
enrollment period. You may also obtain coverage at other times throughout the
year if you apply within 30 days of an event which makes you newly eligible for
the coverage, and, in some cases, within 63 days of a termination of any prior
creditable coverage. You should contact the Division of Insurance to find out if
the 63 day enrollment period applies to you.
The first open enrollment period is expected to be held between October 1, 1997
and November 30, 1997 for coverage to be effective on January 1, 1998. In
future years, the open enrollment period will be held between September 1 st and
October 3 1st for coverage to be effective on December 1st ofthat year.
Can I be denied coverage because of my medical history?
No. Participating health carriers cannot deny you or your dependents coverage
nor impose any coverage limitations because of medical conditions or prior
medical history. They can only deny coverage if you don't meet the eligibility
requirements set forth in the law, if you live outside of a plan's approved service
delivery system, if you do not pay plan premiums or if you have falsified
information on your application or other plan documents, such as claim forms.
What will be covered in the nongroup plans?
Carriers must offer a plan that includes a standard set of benefits including
emergency, hospital and physician services, preventive care, and prescription
drugs administered on an outpatient basis. Although carriers may offer more than
the standard benefits, they must offer at least the standard benefits as designed by
the Nongroup Health Insurance Advisory Board. Carriers may impose cost-
sharing (such as deductibles and co-payments), but the amounts cannot be greater
than those approved by the Commissioner of Insurance for the standard plans.
There will be three types of standardized plans offered in the market:
• Medical plans, without any restrictions on choices of medical
providers. This is a traditional health plan in which you may go
to any licensed hospital, doctor, or provider for your treatment.
In the standard plan, you will be required to pay an annual
deductible ($700 per member/$1,400 per family) and 20% of the
cost of most covered services.
• Preferred provider plans, with incentives to go to preferred
providers. In these plans, you may go to any licensed hospital,
doctor or provider, but you will pay a smaller share ofthe cost if
you go to providers on the preferred list. In the standard plan,
you will be required to pay an annual deductible ($250 per
member/$500 per family) and 10% of covered services from
preferred providers and 30% from all other providers.
HMOs
• Managed care plans, offered by with closed networks of
providers. Except in cases of emergency and specific situations,
HMO
you must use providers within the network in order to
receive benefits. In the standard plan, there are copayments
ranging from $15 for each office visit to $500 for a hospital stay.
What about the coverage already have?
I
Nongroup health insurance plans that are currently in existence (that is, those
plans offered before the new law) will not be sold by insurance carriers on or after
October 1, 1997. As of that date, the plans will be closed to new enrollment
except for new dependents. If you were enrolled in a nongroup plan prior to
September 30, 1997, you should check with your health carrier to determine if
your coverage will be continued after December 31, 1997.
How much
will cost?
it
Participating carriers will offer a product with rates that can vary based only upon
a person's age, family type, place of residence, and premium payment mode. You
can call any of the insurers listed or your agent directly for specific information
about the plans and the cost for you. The attachment lists the companies that are
offering products and examples of what the monthly rates would be for certain
types of persons. You can contact the Division of Insurance at 617-521-7777 for
general information about pricing practices, and call the company for information
about the approved rate for your age, family type and place ofresidence.
Are there any other options ifI can't afford health insurance?
Yes, there are a number of different health programs that might assist you or your
family. They are:
MassHealth a comprehensive health insurance program and premium assistance
:
program for parents, children, senior citizens, and persons who are disabled or
unemployed. Call 1-800-841-2900 for more information and an application.
Children's Medical Security Plan a limited health insurance program for
:
children providing only primary and preventive health. Call 1-800-909-2677, or
in Berkshire, Hampshire and Franklin counties, call 1-800-344-5682.
Medical Security Plan Health insurance for people collecting unemployment
:
benefits. Call 1-800-914-4455 for more information and an application.
In addition to the above, if you have a medical emergency and you do not have
health insurance, you can ask the hospital for an application for "free care."
Whom
should I call for additional information?
If you have any general questions about the standard plans, allowable pricing
practices, or the new law, you can contact the Division of Insurance Consumer
Section in Boston at [phone] or in Springfield at [phone]. Ifyou
have questions about any ofthe specific plans being offered, you should call the
company or the company's agent directly.
Here are some ofthe questions you might want to ask your agent or the health
insurance company when making your decision:
How
• do choose a doctor, and can change doctors?
I I
• Do I have to use specific doctors or hospitals? If so, is my doctor part of the
plan's provider network?
• What happens if I don't use a doctor or hospital on the network list?
• What happens if my doctor leaves the plan's network?
How
• do obtain prescription medications?
I
• How does the company bill for premiums, and how do I want to pay? Do I
have any options in how I pay my premiums (e.g., monthly, quarterly or
semiannually; by check or bank withdrawal)?
Can I enroll directly with the company or does an intermediary or association
have to process my paperwork? Are there any additional costs for enrolling
through associations or intermediaries?
my am
If I pay in advance and later decide to cancel coverage, I entitled to a
How
refund of any advance payment? would the refund be calculated?
Do I have to file claims? If so, how is it done?
IfI have to file a claim, how long does it take to process the paperwork?
What is the procedure ifI have a complaint?
Is there a local office to help me with questions or problems?
1
—
1
Massachusetts
Nongroup Health Insurance Plans
to be Offered for Sale on or after October 1, 1997
Plans by geographic area Page
1
List of plans:
Aetna Life Insurance Company Page 2
Aetna U.S. Healthcare Inc. Page 2
Arbella Life and Health Insurance Company Page 3
Blue Cross and Blue Shield ofMassachusetts, Inc.
HMO
(including Blue) Page 3
Community Health Plan Page 4
Fallon Community Health Plan, Inc. Page 4
Gerber Life Insurance Company Page 5
The Guardian Life Insurance Company ofAmerica Page 5
Harvard Pilgrim Health Care, Inc. Page 6
New
Health England, Inc. Page 6
Healthsource Massachusetts, Inc.
CMHC)
(doing business as Healthsource Page 7
John Alden Life Insurance Company Page 7
MEGA
The Life Insurance Company Page 8
New England Life Insurance Company Page 8
—
New York Life Insurance Company Page 9
PFL Life Insurance Company Page 9
Tufts Associated Health Maintenance Organization, Inc.
(doing business as Tufts Health Plan) Page
1
United HealthCare Insurance Company Page 10
=
New
United HealthCare of England, Inc. Page 1
Most companies have filed rates that vary according to a person's age and
place ofresidence. Rates in the brochure are samples ofrates filed by each
company and will be updated as new carriers file. Call the company for the
rates that apply to you.
Please note that certain plans are only available in certain parts ofthe state.
Check page to see which plans are offered in your area.
1
Prepared by the Division ofInsurance based on information available as of 10/20/97.
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