10 Acts That All Health Insurance Companies In The USA Must Comply With

Introduction:

            Health insurance in the United States has been around since the days of Ancient Rome and has seen significant changes since then. If you’re looking to purchase health insurance, you should make sure that your chosen health plan meets the following requirements set by the federal government.

 Here are 10 acts that all health insurance companies in the USA must comply with

1) Treat Every Customer Fairly

            America has over 300 million people, and there are no doubt a lot of different ways that these people want to be treated by their insurance companies. One man's idea of good customer service might not be another's. To stay in business and make as much money as possible, every health insurance company in America must treat every one of its customers fairly, whether or not that customer is older or younger, richer or poorer, male or female, etc. This means that insurance companies can't target certain demographics for higher premiums; it also means they can't charge different amounts for certain types of services (in other words, they can't provide free medical care for one ailment but charge a ton for another). Every American deserves fair treatment from his or her health insurance company.

2) Provide Transparency About Services Offered

            All healthcare plans, whether they’re provided by an insurance company or a third-party administrator, must provide transparency about what services they offer. If you choose a plan with 100% coverage for certain procedures, you should know that upfront. Likewise, if a service is not covered under your plan but you seek it out regardless and get it anyway—paying out of pocket—your company shouldn’t come back to bill you later on (the risk is yours). When shopping for health insurance, read through each plan carefully and look for specifics about which services are covered. Also, make sure to ask about any limitations on medications or other procedures as well as pre-authorization requirements. You can use our guide to choosing a health insurance plan here.

3) Inform Customers About Their Rights

            U.S. laws are pretty clear on what health insurance companies must tell customers and why. Under both federal and state laws, health insurance companies must provide information about their benefits in a way that is easy to understand. They must also let customers know how much they would pay out of pocket for medical services before any insurer-paid benefits kick in. A patient’s maximum out-of-pocket expenses include all copayments, coinsurance, deductibles, and other costs that might otherwise be paid by a customer before his or her insurance company steps in to cover medical bills. And, while it may seem obvious, it’s worth mentioning that insurers must comply with these rules regardless of whether they offer coverage through an employer or directly to consumers via an individual plan. This means that whether you get your health insurance through your employer or buy it directly from an insurer like Blue Cross Blue Shield, you have rights when it comes to understanding how your plan works.

4) Allow Customers to Sue Over Violations

            This one seems like a no-brainer, but health insurance companies aren’t always held accountable if they don’t comply with certain rules. This can especially be true when it comes to terms that may seem unfair, such as mandatory waiting periods for pre-existing conditions or limitations on how much can be reimbursed for certain services. If you feel you were wronged by your insurance company, make sure you understand your rights and know-how to pursue damages if need be. Many of these regulations are designed to ensure consumers get quality care at a fair price and patients will likely have access to some sort of appeals process if they feel their rights were violated. While there is no guarantee your claim will be honored, most states do provide some form of legal recourse. And if not, you might consider contacting an attorney who specializes in insurance law. (If you live in California, for example, check out our directory.)

            The Affordable Care Act (ACA) was passed in 2010 and has already made significant changes to what constitutes qualified health coverage under federal law—most notably through its mandate that insurers cover individuals with pre-existing conditions beginning in 2014. Under ACA guidelines, insurers must also provide ten essential benefits including prescription drug coverage and preventive care. While many states have already enacted similar laws before ACA implementation, all plans sold in America must now meet ACA requirements—and those requirements should only grow stronger over time.

5) Admit When They Are Wrong

            Even if it costs a company some money, it’s always better to admit fault and fess up to mistakes than let them hang out there or bury them in legalese. Sincere apologies can help repair damaged relationships with customers, but overblown corporate speak or straight-up denial makes a bad situation worse. A little common sense goes a long way. As Ralph Waldo Emerson onetime said, If you swat at a king, you must destroy him. You don’t want your reputation as an honest company compromised by saying you made an honest mistake. Be upfront about issues from day one and go ahead and deal with that bad apple who is giving you all those terrible reviews on Yelp. It’ll be worth it in the end. 

            For example, Comcast’s Executive Vice President of Customer Service Dave Watson apologized for what he called unacceptable service during a recent outage. The apology came with $60 million in credits for customers, which should make people feel better even if they are still angry. Besides this, Watson was probably feeling pretty ashamed himself after he got caught singing his own praises (in song) while thousands of his company's customers were suffering through another outage. Just imagine how much more painful that would have been having him not owned up to his part in things right away? He could have even gotten fired! Or maybe we're just paranoid...who knows?

 

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6) Prohibit Price Discrimination Based on Pre-Existing Conditions

            It is illegal for health insurance companies to discriminate against people with pre-existing conditions. While health insurance providers may not be allowed to set their prices based on a person’s medical history, they can vary premiums based on factors like age and industry. Insurers are free to charge different premiums for men and women since it is often difficult for them to accurately predict how much an individual will cost down the road. Premiums are also commonly higher for older individuals, as life expectancy is slightly shorter for seniors than it is for younger people. 

            However, there are limits to what insurers can charge older patients. Since these patients have already paid into Medicare, they cannot be charged more than three times what a young patient would pay in any given year. They also must cover certain essential benefits that help all Americans maintain good health. For example, all plans must cover prescription drugs and emergency services. History of Health Insurance: People have been trying to figure out ways to pay for healthcare since time immemorial.

7) Do Not Discriminate Against Those Who Are Uninsured

            It's illegal for health insurance companies to deny coverage or charge higher premiums based on a preexisting condition. A preexisting condition is a term used to describe any type of chronic illness, injury, illness, or disability that was present before your plan coverage starts. Additionally, it is illegal for insurers to discriminate against anyone who does not carry private insurance; this means you can't be charged more for your services because you don't have health insurance coverage through an employer. 

            This provision does not mandate coverage under private plans and only applies to those people who are attempting to purchase individual plans on their own through state-run exchanges. There is no federal law requiring employers to provide health insurance for employees. Some states do require employers to offer group health care plans if they have a certain number of employees working in their company, but there are no federal mandates requiring employers to offer such benefits. If you're looking for affordable medical care but aren't insured, there are several options available depending on your income level and situation. 

            Medicaid: Medicaid provides free or low-cost medical care to low-income individuals who meet specific eligibility requirements. Eligibility requirements vary by state, but all states must cover pregnant women with incomes at or below 133 percent of the federal poverty level (FPL). However, each state has its own rules regarding eligibility requirements beyond pregnancy status.

8) Offer Affordable Plans to Low-Income Individuals

            No matter what healthcare reform turns out to be, those who can least afford healthcare will need some form of assistance. Those at or below a certain percentage of their state’s median income—usually 130%—can get additional help from Medicaid or CHIP. Of course, not all states have these programs, so check on your state specifically if you’re interested in seeing if you qualify for financial assistance. If you do receive assistance with your premiums, don’t forget to apply for any available cost-sharing subsidies and tax credits. 

            These lower costs on insurance can really add up over time and can help offset rising premium prices. Even if you aren’t eligible for financial assistance, make sure to shop around during open enrollment season (this year from November 1 – December 15) to see which plans are offering new discounts and deals. You might just find a deal that makes your health insurance more affordable than ever before!

9) Provide Free Preventive Care

            Unfortunately, many health insurance plans still deny coverage for care that could help you avoid future hospitalization and costly procedures. Ask your doctor if there are any screenings or vaccines that you should receive—and then ask your insurer what they cover. If they deny services based on your gender, race, medical history, or pre-existing conditions (like pregnancy), it’s time to switch insurers. You also need to verify that any out-of-network physicians and providers you plan to see are in-network for your plan (many aren’t) and make sure you understand how much you will be responsible for paying out of pocket. This is especially important if you have a high deductible health plan.

            The Affordable Care Act requires all new individual and small group plans to provide preventive care with no cost-sharing beginning August 1, 2012. However, some older plans may not comply with these new rules until their renewal date in 2014. Check with your state department of insurance for more information about whether your specific plan must comply with these new rules now or at renewal.

10) Encourage Obamacare Enrollment

            Currently, a lot of people are considering alternative options to Obamacare insurance and if you’re one of them then your research probably isn’t stopping at health insurance. At its core, Obamacare helps provide healthcare to people who can’t afford it by extending Medicaid coverage and offering tax credits for low-income families. However, these benefits don’t apply to everyone because every state has decided whether or not they want to participate in expanding Medicaid. 

            In a majority of states like Texas, Florida, Alaska, and Arizona, residents are having trouble finding affordable healthcare options through their local exchange. Luckily, there are several alternative insurance plans available including short-term plans and association health plans. These types of plans have been growing in popularity recently as more people realize that they don’t have to be stuck with an expensive plan just because they live in a state that doesn’t offer any better alternatives.