Health insurance is the issue that the people of Delaware talk to me about the most. Dealing with health insurance and health insurance companies can be complicated and very confusing. That’s one of the reasons my office is here.

The Consumer Services staff in the Insurance Commissioner’s Office is trained  and experienced in dealing with health insurance problems. Whether it’s a simple question or a tough situation where someone is being denied a medical treatment, we will do everything we can to help you understand your options and will contact the insurance company on your behalf if necessary. I often take on these cases myself, because, to me, there is no more important job in our department than helping consumers.

Please contact us if you need help. We know that someone's health is often on the line.

Many medical plans typically cover a comprehensive array of health care needs, including doctors’ visits, drugs and hospital care.  These benefits can be delivered in several different ways:

Indemnity plan. These medical plans typically have a deductible – the amount you pay before the insurance company begins paying benefits. After your covered expenses exceed the deductible amount, benefits usually are paid as a percentage of actual expenses, often 80 percent. These plans usually provide the most flexibility in choosing where to receive care.

Preferred Provider Organization, or PPO. In these medical plans, the insurance company enters into contracts with selected hospitals and doctors to furnish services at a discounted rate. As a member of a PPO, you may be able to seek care from a doctor or hospital that is not a preferred provider, but you will probably have to pay a higher deductible or co-payment.

Health Maintenance Organization, or HMO. These medical plans make you choose a primary care physician, or PCP, from a list of network providers. Your PCP is responsible for managing all of your health care. If you need care from any network provider other than your PCP, you may have to get a referral from your PCP to see that provider. You must receive care from a network provider in order to have your claim paid through the HMO. Treatment received outside the network is usually not covered, or covered at a significantly reduced level.

Point of Service, or POS. These medical plans are a hybrid of the PPO and HMO models. They are more flexible than HMOs, but do require you to select a primary care physician (PCP). Like a PPO, you can go to an out-of-network provider and pay more of the cost. However, if the PCP refers you to an out-of-network doctor, the health plan will pay the cost if the insurance plan has authorized the referral.

While many health insurance plans are regulated by the Delaware Insurance Commissioner, some are not.

Basic Hospital Expense Coverage covers a period of usually not less than 31 days of continuous in-hospital care and certain hospital outpatient services.

Basic Medical-Surgical Expense Coverage covers costs associated with a necessary surgery, including a certain number of days of in-hospital care.

Hospital Confinement Indemnity Coverage covers a fixed amount for each day that you are in a hospital.

Accident Only Coverage covers death, dismemberment, disability or hospital and medical care caused by an accident.

Specified Disease Coverage covers diagnosis and treatment of a specifically named disease or diseases – such as cancer.

Other Limited Coverage. You may purchase insurance covering only dental or vision or other specified care.

Additional coverage options provide added protection should you become disabled, require long-term care or enroll in Medicare:

Disability Income provides for weekly or monthly benefit payments while you are disabled after a covered injury or sickness.

Long-Term Care Insurance usually pays for skilled, intermediate and custodial care in a nursing home as well as care in other settings, such as the home, adult day care center or assisted living facility. The policy usually pays a fixed amount per day while a person is receiving care.

Medicare Supplemental Coverage. The federal Medicare program pays most medical expenses for people 65 or older, or for individuals under 65 receiving Social Security disability benefits.  However, Medicare does not pay all expenses. As a result, you may want to buy a Medicare Supplement policy (also known as Medigap) to help pay for certain expenses, including deductibles not covered by Medicare.

Here are two types of health-related services that are not health insurance plans:

Discount Plans or Discount Cards. You may see or receive advertisements from plans offering discounts on health care for a monthly fee. These are not health insurance plans, and participants do not have the same protections as under licensed health insurance.

Discount cards do not pay medical claims. Instead the consumer with the card is responsible for paying for services at the time care is received. Many of the discount plans do not cover all types of services and conditions. And the discount card is only good with doctors and health providers that have agreed to accept it.

Some of the discount cards use high-pressure marketing tactics and ask for a large, upfront fee. They are often advertised via spam emails, internet pop-up ads, on roadside signs or on telephone poles. 

Commissioner Denn strongly recommends that you thoroughly investigate any plan promising deep discounts for a “low” monthly fee and weigh the benefits against the costs carefully.

Non-Licensed Risk-Sharing Plans. You may receive offers to join a group or association that will take your monthly payments, put them in a savings account, or trust, with other participants’ money, and then help pay some of your health care costs, as needed.

Such arrangements are not insurance and the participants do not have the protections available to purchasers of licensed insurance plans. Commissioner Denn strongly recommends that you thoroughly investigate such plans before joining.

Medical discount cards and risk-sharing plans are not insurance and are not regulated by the Insurance Commissioner’s Office, thus the office has no ability to force such plans to take any action should a consumer have a problem.

If you’re married and both spouses work at jobs that provide health insurance, compare your policies and their costs to see which one best fits your needs. Look beyond the monthly amount you must pay and closely evaluate covered services, co-pay requirements, deductibles and reimbursement levels so that you make the best choice for your family and your pocketbook.

Many plans offer a menu of options. Review your situation regularly, and adjust your options to meet changing needs.

Stay in your network as much as possible, making sure to obtain referrals as required.

Many plans require pre-certification for certain tests and procedures.  Know your plan, and make sure you comply with these requirements to avoid paying penalties.

Hold on to all receipts for medical services. Even though your intent may be to always stay in-network, you never know when an accident, out-of-town emergency room visit or unexpected illness might cause you to incur out-of-pocket expenses that exceed even a high deductible.

Check to see if your employer offers a flexible spending account.  These plans, which allow you to set aside pre-tax dollars for medical expenses and childcare, are a good way to reduce your out-of-pocket medical costs.

Finally, consider combining a high-deductible catastrophic plan with a Health Savings Account, or HSA. An HSA is a tax-sheltered savings account similar to the IRA, but earmarked for medical expenses. Deposits are 100 percent tax-deductible for the self-employed and can be easily withdrawn by check or debit card to pay routine medical bills with tax-free dollars. Larger medical expenses are covered by a low-cost, high-deductible health insurance policy. What is not used from the account each year stays in the account and continues to grow interest on a tax-favored basis to supplement retirement, just like an IRA. Some employers offer HSAs to their employees as an option.

Before you make a claim: Review your policy or employee booklet carefully to be sure the service in question is covered. Follow any managed care rules, including pre-certification requirements and use of network providers. Give claim forms to the provider, with your policy number and other identifying information.

To submit a claim properly: Find out if your provider submits the claim for you or if you need to do it. If you need to do it, review the information to be sure it is complete and correct. File it as soon as you get the bill from the provider. Send it to the right address. Keep a copy for your reference.

Time frame for claims: Delaware's "Prompt Payment" regulation basically requires the insurance company to pay a claim, reject it or ask for more information within 30 days. It also requires that a health insurance company only ask for additional information once, rather than repeatedly making requests. The company must send you an explanation of benefits that explains its decision.

If your claim is paid: If you assigned benefits to the provider, the benefit check will be sent directly to the provider. You will pay any deductibles and co-insurance. If you did not assign the benefits, the check will come to you and you will need to pay your providers for the entire amount.

If your claim is denied: The reason for denial should be stated on your explanation of benefits. If you disagree with the basis stated for denial, check your policy or employee booklet for the company's appeal procedures.

The company should be able to answer procedural questions about appeals over the phone. Your appeal should be in writing and may require information from your doctor or health care provider.

If, after going through the company's appeal process, you feel that your claim was unfairly denied, contact the Insurance Commissioner’s Office at consumer@state.de.us or call 1-800-282-8611. Often, companies will resolve disputes after a Consumer Services representative intervenes on the consumer's behalf.

There are ways that you may be able to keep your health coverage for a period of time when you leave a job. The first step is to figure out if you qualify for “COBRA” and the second is to determine whether you are eligible for coverage under “HIPAA.”

COBRA (which stands for the Consolidated Omnibus Budget Reconciliation Act) is a federal law that allows you to extend your current group health insurance coverage when you leave a job, are fired from a job (for reasons other than fraud or misconduct), are reduced from full-time to part-time status, or another “qualifying event” occurs. You can extend the coverage — at your cost — for 18 months, and sometimes longer. PPOs, HMOs, indemnity policies and self-insured plans are all subject to COBRA, but your employer must have 20 or more employees.

If you leave a job and use COBRA to continue your health coverage, you will still have the same plan with the same benefits and provisions, but you will pay much more for it. That’s because your employer was paying part of your premium before and now you will be responsible for paying all of the premium. Ask your employer’s human resources staff to use COBRA.

If you are not eligible for COBRA, if your employer is not covered by it because the your employer has fewer than 20 employees, or if you have used COBRA and the time period has run out, you may be able to purchase health coverage under the federal Health Insurance Portability and Accountability Act, or HIPAA. If you meet the definition of an eligible individual under HIPAA, all health insurance companies who sell individual plans must offer you health insurance regardless of your medical history and even if you have a pre-existing condition.

To qualify under HIPAA, you must have had health care coverage for the last 18 months under an employer-sponsored group health plan (COBRA coverage counts). You must not be eligible for any other group health plan, Medicare or Medicaid. You must not have lost your most recent health coverage due to fraud or not paying. There are other restrictions as well. If you request a HIPAA-guaranteed policy within 63 days of losing your previous health coverage, most health insurance companies in Delaware are required to offer you a choice of two policies.

If you have questions about whether you qualify for coverage under COBRA or HIPAA, contact the Insurance Commissioner’s Office at 1-800-282-8611 or email consumer@state.de.us.

For those whose health coverage does not include prescription drugs, here are some resources on the internet for possibly obtaining needed prescriptions:

www.together-RX.com  (or 1-800-865-7211)

www.helpingpatients.org

www.benefitscheckuprx.org

www.needymeds.com

www.pfizerforliving.org (or 1-800-717-6005)

You may also want to speak to your doctor or medical provider about any direct pharmaceutical company programs they know of that provide prescriptions to those who cannot afford them.

Questions about insurance or complaints about an insurance company or insurance agent can be made to the Commissioner's Consumer Services division by phone, by fax, by letter, by email or with an online complaint form:

Call 1-800-282-8611 toll-free in Delaware or (302) 674-7310

Fax a complaint to (302) 739-6278

Mail to 841 Silver Lake Blvd. Dover, DE 19904

Email to consumer@deins.state.de.us

Use the online complaint form

If you have a choice of companies for your health care coverage, use these questions to help compare the plans:

What’s Covered? What does the plan pay for and not pay for? Are there limits on pre-existing medical conditions? Does it pay for preventive care, immunizations, well-baby care, substance abuse, organ transplants, vision care, dental care, infertility treatments, durable medical equipment or chiropractic care?

What Are The Premiums? How often can rates change? Do rates increase as you age?

What Are The Out-Of-Pocket Expenses? What are the co-payments and deductibles you will have to pay when you receive care? Are there limits on your out-of-pocket expenses? Are there any limits on how many times you can receive a service in a year or in your lifetime?

What About The Company? Check with the Department of Insurance to make sure a company is licensed to do business in Delaware, to find out its financial stability rating from A.M. Best Co., and to find out its complaint history.

Under a new law advocated by Commissioner Denn, many parents in Delaware can purchase health coverage for their adult children up to age 24 under the parent's policy so long as the child is in college or lives in Delaware. For more information, click here.

For children up to age 18, low-cost health insurance is available for families with low incomes, including working families whose job does not provide or who cannot afford other health insurance. Click here to find out more.

What should young adults look for in health insurance?

As health insurance in the U.S. is typically employer-provided, getting a job is often the first time a young person begins to think about this matter.

While you are young and healthy, you might actually feel that you don’t need health insurance. In fact, you might be tempted to do without coverage because you are strapped for cash and want to avoid paying the premiums.  The National Association of Insurance Commissioners recently surveyed U.S. consumers and nearly a fifth of young singles indicated they would decline employer health insurance to save money.

However, forgoing health insurance is a dangerous decision.  Accidents and unforeseen illnesses can be financially devastating for you and your family. Weigh carefully the repercussions of not being covered, and seriously consider buying health insurance suited to your needs.

Know your family’s health history. If you are at high risk for developing a medical condition – such as diabetes – later in life, think carefully before saying no to your employers’ health policy, even if it means paying higher premiums while you are young and healthy.

 Understand that if you have been covered under your parents’ health insurance policy while you were in college or by a plan offered through your college, often this coverage ceases when you graduate. Additionally, many companies have employee probation periods before health coverage goes into effect. For these periods of no coverage, you should check to see whether you can extend your parents’ coverage short-term under COBRA.  Some colleges also offer graduates interim coverage.  As an alternative, talk to an insurance agent about purchasing catastrophic health coverage as a short-term measure.

As you sort through job prospects, don’t make the salary your sole priority. Health coverage is perhaps the most important job-related benefit you can receive; so study the health plans that prospective employers provide. Many companies have coverage through an HMO or a managed-care plan, which means that many decisions – including which physicians are included in the network – are made by the healthcare provider. Others have more flexible plans that allow their participants to choose their physicians. In either case, the employee is responsible for co-payments which help keep costs under control.

 Here are some ways that you can control your health insurance costs or cover an interim period before or between jobs when you are not under an employer’s plan:

If you feel you can’t afford regular health insurance, a more affordable option you may want to consider is purchasing a high-deductible major medical policy that only covers very serious or catastrophic health costs.  It will offer lower premiums than regular health insurance policies and help you cover bills for “major” medical events, like surgery, hospitalization or emergency room care.  But it will typically not cover routine doctor visits or check-ups. 

 If you are convinced that you are generally healthy and have a healthy lifestyle and definitely do not want to pay (or can’t afford to pay) high insurance premiums, consider a Health Savings Account.  HSAs can be set up individually or, increasingly, as an option through employers.  They allow you to accumulate and spend pre-tax money for health expenses via an account that you own and can take with you should you change jobs.

If you are in a physically demanding job, you might want to consider purchasing disability insurance, as research shows that young people are four times more likely to be disabled than die at an early age.  As an option, many employers offer disability coverage, which provides lost income in the event that you are injured and unable to work. If the injury is work-related, then workers compensation coverage applies.

 If you decide to purchase disability insurance, try to get a non-cancelable, guaranteed renewable policy. That means it can never be canceled and it's good until age 65.  Make sure you review your disability policy on an annual basis to ensure any disability payments continue to keep pace with your increase in earnings.

 

What should young families look for in health insurance?

Here are some special considerations for young families:

If both parents are working in full-time jobs, it is recommended that you compare these health insurance policies to see which best fits the needs of your family: Employee; Employee and Spouse; Employee and Family; Employee + one, where the spouse has separate coverage

Make sure to review the co-pay amounts and different options carefully to see exactly what is covered – and what isn’t – for both parents and children.

Check to see if your employer offers a flexible spending account.  These plans, which allow you to set aside pretax dollars for medical expenses and childcare, are a good way to reduce your out-of-pocket medical costs.

When expecting a child, review the coverage options available to you, and find out exactly how your healthcare plan handles the costs. Remember to consider the costs of prenatal vitamins, prenatal and neo-natal screenings and tests, emergency procedures, delivery – C-section and traditional – and pediatric care.

Also, make sure you are aware of the deadline to register your newborn with your health insurance company. Consult with your employer and health insurance provider regarding the requirements before your child is born.  If you decide to adopt a child, consult with your employer and health insurance provider regarding the requirements for obtaining health insurance coverage in advance, and also check with your state health department.

What should midlife families look for in health insurance?

As your family matures, its health needs change.  Thus when your annual enrollment date approaches for employer-provided health insurance, recognize that you may want to alter elections or eliminate certain types of coverage, if you have the choice.

For example, if you and your spouse have decided not to have more children, you may not be interested in a policy that covers pregnancy-related services.  But note that if you decline pregnancy-related coverage and your teenage daughter becomes pregnant, she will not be covered. If you still have young children, consider a program with a preventative care option that provides shots and “well visits”. 

Keep in mind that health insurance policies will most likely not cover some common childhood procedures and problems, such as allergy tests, braces, and replacements for lost eyeglasses, contacts or retainers. Consider contributing money to a flexible spending plan, if your employer offers one, to help you put aside pretax money to cover these types of expenses.

Know your rights and entitlements under COBRA – the Consolidated Omnibus Budget Reconciliation Act.  If you lose or change your job or decide to start your own business, be sure to familiarize yourself with COBRA so that you’re clear how your family will be covered when your situation changes.

If you’re over 50, you may want to consider whether long-term care insurance make sense for you. Before purchasing long-term care insurance, do a thorough analysis of your financial situation to be sure you can continue to afford the premiums for an extended period of years – through your old age until death – and figure out whether you have significant savings or other financial assets you want to protect.  Many people find they cannot afford the premiums as they get older and get closer to the point when they are most likely to need the coverage.  In addition, make sure you know what triggers will result in benefit payments, as well as the likelihood and potential size of premium increases.

 

What should seniors look for in health insurance?

As you age, health insurance considerations become paramount.  Here are several issues you need to address:

Are your children still in college full-time?  You may be able to cover them under your existing health plan if you are still employed.  If your children are in college out-of-state, you may need to explore a health plan through the school or from a private insurance company in the geographic area where they are living for most of the year.

If you decide to retire or have been laid off from your job before you turn 65 – and you are not yet eligible for Medicare, what do you do?

Check to see if you are eligible to continue to get health insurance at the group rates from your former employer under COBRA (Consolidated Omnibus Budget Reconciliation Act).  COBRA is a federal law enacted in 1985 that typically entitles you to continue your employer’s coverage for up to 18 months.  Note that you will be responsible for paying the premiums for this insurance and that you must let your former employer know within 60 days of leaving your job if want to continue your health benefits.

If you are no longer employed and your COBRA benefits have run out – but you are still not yet eligible for Medicare – you might want to consider a catastrophic or high-deductible medical plan which typically carries lower premiums than other individual policies.  The caveat here is that people with serious pre-existing health problems like heart disease, diabetes or Multiple Sclerosis typically can’t get catastrophic health insurance.

Be wary of health discount cards.  If you are considering the purchase of a health discount card of any sort – for example to cover pharmaceuticals, dental care or doctor visits – be sure to investigate whether the insurer is legitimate by calling your state insurance department.  Also research how many complaints have been filed against that insurer and find out exactly what is covered and whether your physician/dentist accepts the card.

Consider whether you still need disability insurance.  Important considerations include whether you are still employed, your age, how many years you have until eligibility for Social Security, your individual financial needs and your ability to pay the premiums, which typically escalate significantly as you age. 

Carefully evaluate whether long-term care insurance make sense for you. Before purchasing long-term care insurance, do a thorough analysis of your financial situation to be sure you can continue to afford the premiums for an extended period of years – through your old age until death – and figure out whether you have significant savings or other financial assets you want to protect.  Many people find they cannot afford the premiums as they get older and get closer to the point when they are most likely to need the coverage.  In addition, make sure you know what triggers will result in benefit payments, as well as the likelihood and potential size of premium increases.

Where can I find the definition of common health insurance terms?

Click here for a list of health insurance terms.

What are the major health insurance companies offering coverage in Delaware?

The following are the top 5 companies that provide health insurance in Delaware, based on 2006 figures. Together, they account for the vast majority of the health insurance coverage in the state. They are listed by name and the premium volume (in dollars). 

Are there proposed laws in Delaware that would make health insurance more affordable?

Insurance Commissioner Denn has proposed and supported a number of measures in the General Assembly to address the high cost of health care. You can find descriptions of these proposals and their status in the state legislature here.