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Health Insurance Claim Filing Ohio - PDF

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									                          Ohio Consumer Guide Series

                            Ohio Department of Insurance
                        1-800-686-1526   •

Guide to Health Insurance
   How to find, keep and use health insurance

Ted Strickland                                    Mary Jo Hudson
Governor                                                  Director

                   September 2008
                 Governor Ted Strickland
                 Department of Insurance
                 Director Mary Jo Hudson
The Ohio Department of Insurance has created this consumer
guide to provide you with basic information about health
insurance. This guide describes the various types of coverage
available in Ohio, defines common health insurance terms and
offers easy-to-read questions and answers that can apply to
people in different situations and life stages. The guide also
describes your rights if you have a dispute with your company
about coverage.

Please do not use the guide as a replacement for the detailed
information found in your health policy, certificate or benefits
booklet. Be sure to review and understand your coverage
before you have a claim.

If you have any questions, please visit the Ohio Department of
Insurance web site — — or call the
Department’s Consumer Services Division at 1-800-686-1526.

Best wishes,

Ted Strickland

Mary Jo Hudson
Director, Ohio Department of Insurance
                   Table of Contents
The basics of health insurance ................................ 2
Possible additional benefits in Ohio plans ................ 6
Choosing a plan / understanding your plan .............. 8
Helpful phone numbers and web sites...................... 9
What’s your situation? ............................................. 9
Getting individual health insurance ......................... 10
Young adults ........................................................... 12
Families .................................................................. 13
Job change / Job loss ............................................. 16
Surviving without health insurance ......................... 20
Running a small business or self-employed ........... 22
How to appeal a decision by your health plan ........ 24
About the Ohio Department of Insurance ............... 25
Glossary of terms.................................................... 26

       Disclaimer notice:
       The information included in this publication is meant to serve as
       a guide and is not a substitute for legal or professional advice.
       Please be certain to check with a professional if you have questions
       Published in September 2008. May change without notice.
                     The basics of health insurance
The Ohio Department of Insurance has               Types of comprehensive health
created this guide to help you understand          insurance plans
some of the basics of health insurance. This
                                                   Comprehensive health insurance plans can
guide is intended to help individuals, families,
                                                   be offered by employers or on an individual
self-employed people and small business
                                                   basis through a variety of insurance
owners evaluate their options.
                                                   companies. Coverage can be in the form
                                                   of managed care or traditional health
If you have health coverage, try to keep
it. Unless the policy owner (you or your
employer) stops paying premiums, the health
plan cannot cancel your coverage — even            Managed care
if you get sick. The law allows you to keep        Managed care is a type of health delivery
coverage through life-changing events              system that includes participating providers
(divorce, changing jobs, job loss, etc.)           who contract with the health plan. The
                                                   providers manage the care of their patients.
Not having health insurance can be a               Types of managed care plans include HMOs
dangerous decision. If you’re not covered          (called health insuring companies — HICs —
and have an accident or develop a serious          in Ohio), PPOs and POS plans.
illness, it can be financially devastating.
                                                   Some managed care plans require you to
What is health insurance?                          have a Primary Care Physician (PCP). If so,
                                                   you must rely on your PCP anytime you need
Health insurance is a general term used to
                                                   a service.
describe many kinds of insurance coverage.
For most people, the term “health insurance”
                                                   When appropriate, the PCP will refer you to a
means comprehensive health insurance.
                                                   specialist within the plan’s network. The plan
                                                   may allow you direct access to the specialist
This is the broadest kind of health insurance
                                                   depending on the seriousness of your
and covers most of the cost of keeping
                                                   condition or if you require specialized care
you healthy and getting you healthy if you
                                                   over a long period of time.
become ill. Comprehensive health insurance
includes doctor visits, hospital care, tests,
certain therapies and sometimes prescription
drugs. Medicare and Medicaid provide such
comprehensive coverage to eligible people.

Health Maintenance Organizations (HMOs)          Traditional health insurance
Health Maintenance Organizations are             Under traditional major medical insurance,
prepaid health plans in which individuals        you are covered to use any hospital or doctor.
or employers pay a monthly premium. In
exchange, the HMO provides comprehensive         Traditional insurance plans normally require
care for you and your family, including doctor   you to pay a monthly premium, an annual
visits, hospital stays, emergency care,          deductible and coinsurance for each service.
surgery, lab tests, x-rays and therapy.

Except in an emergency, HMOs usually do not
                                                 Coverage provided by employers
pay anything toward your care if you do not      Most Ohioans get health insurance coverage
use the plan’s network providers.                through their employers. It is important to
                                                 understand, however, that employers offer
Members generally must make a copayment          insurance voluntarily — no law requires it.
for services and use doctors in the network.
Out-of-pocket costs are likely to be lower and   The employer may offer insurance that covers
more predictable than in an indemnity or fee-    you only, or may offer coverage to you and
for-service plan.                                your dependents. Plan coverage details may
                                                 be based on whether you are part of a large
Point-of-Service (POS)                           or small employer group.
A POS plan, also known as an open-ended
                                                 Some large employers “self-insure” the
HMO, is a blend of HMO and PPO coverage.
                                                 health benefit plans that cover employees.
You may use doctors in the HMO network
                                                 If your employer is self-insured, it means
or you may choose other doctors. You pay
                                                 the employer, not an insurance company,
a higher cost if you use doctors outside the
                                                 is responsible for payment of your covered
                                                 health care services.
Preferred Provider Organization (PPO)
                                                 These plans may be administered by the
Preferred Provider Organization is a plan that   employer itself or the employer may contract
contracts with independent providers at a        with an outside administrator (often a health
discount for services. The enrollees may go      insurance company) to process claims.
outside the network, but would pay a greater
percentage of the cost of coverage than within   The best way to know if your plan is self-
the network.                                     insured is to ask your employer’s Human
                                                 Resources department.

                                                 Many self-insured plans are not subject to
                                                 state insurance laws. The U.S. Department of
                                                 Labor regulates most aspects of self-insured
                                                 health plans under the Employees Retirement
                                                 Income Security Act (ERISA).
                                                 Call 1-866-487-2365.

Health Savings Account (HSA) with a              Coverage individuals can buy
high-deductible health plan                      directly
Employers may offer Health Savings Accounts      If you cannot get health insurance through
to employees. HSAs are savings funds that        your employer (or your spouse’s / partner’s
allow you to pay some health care costs          employer) or you’re not employed, you may
with tax-free dollars. HSAs let you pay for      be able to buy health insurance coverage
current medical expenses and save for future     for yourself and your family. This is called
qualified medical and retiree health expenses    individual coverage.
on a tax-free basis.
                                                 There are different avenues for buying
In order to use a health savings account you     individual coverage: through the individual
must purchase a high-deductible health plan      private market, (temporary) COBRA or
to use with it. Under a high-deductible health   state continuation, (permanent) conversion,
plan, you pay a lower premium and accept         HIPAA-eligible, or state-sponsored insurance
greater risk.                                    (Medicaid). If you change jobs or leave
                                                 group coverage, you should know your rights
Professional organization plans and              to continue or convert the old coverage.
association plans                                Although the coverage can be costly, you are
Sometimes associations such as local             allowed by law to keep your family covered.
chambers of commerce and professional            See pages 16-19 for this important information.
organizations offer group health plans. You
may also qualify for health insurance through    An insurance agent can help you find
a religious or fraternal organization.           appropriate insurance in the private insurance
                                                 market, or you can call the Ohio Department
                                                 of Insurance at 1-800-686-1526 with
                                                 questions about your options.

                                                 Public health insurance plans
                                                 Depending on your situation, you may qualify
                                                 for a government health insurance program,
                                                 such as Medicaid or Medicare. If you can’t
                                                 afford health insurance, the Ohio Department
                                                 of Job & Family Services — the agency that
                                                 administers Medicaid — may be able to help.
                                                 Call 1-800-324-8680.

Types of non-comprehensive health                  Dental insurance
insurance plans                                    Some companies provide dental insurance
                                                   to their employees and plans are available
Short-term health insurance
                                                   for individuals as well. Plans normally have a
Short-term insurance will generally provide        network of dentists they prefer you to use. You
coverage for no longer than a year. Because        may still get benefits if you use a dentist who’s
you cannot carry eligibility from prior coverage   not in the plan’s network, but your copays will
to a short-term health policy, no short-term       be lower by choosing an in-network dentist.
health policy covers pre-existing conditions.
College alumni associations may offer this         Vision insurance
option to recent graduates.
                                                   Employers may offer vision coverage; plans
                                                   may also be purchased by individuals. Vision
Student group coverage
                                                   insurance is a wellness benefit that helps pay
Many colleges and universities offer health        your costs for eye exams, corrective lenses
insurance to enrolled students and may offer       and other vision services. Some plans require
coverage for an extended period of time after      you to use a provider network.
                                                   Long-term Care (LTC) insurance
Disability insurance
                                                   Insurance that pays for care given in a skilled
Disability insurance is sometimes called           nursing facility, adult care facility or at home.
supplemental income insurance. It pays a           Covers chronic medical conditions and helps
fixed amount for a specified period of time        with activities of daily living.
when you can’t work because of an accident
or illness. Coverage may be short-term or          Other options
long-term. Your employer may offer this
coverage or you can purchase it on your own.       Health discount cards
Benefits and eligibility requirements can vary     Coverage through a discount card is also
greatly, depending on such things as how           not health insurance. Such cards simply
the plan defines “disability,” waiting periods,    discount the cost for medical services when
length of hospitalization and exclusions.          received from certain doctors and other
                                                   providers. Health discount cards can save you
Cancer insurance                                   money but they do not offer the protections
Cancer insurance provides benefits only if         carried by actual health insurance.
you get cancer. Like all insurance products,
the policy will not be offered to you if cancer    If health insurance is not available to you —
was diagnosed before you applied for the           for whatever reason — a discount plan may
coverage.                                          help lower your medical costs. Always read
                                                   the membership agreement and use the plan
                                                   wisely. The Ohio Department of Insurance has
                                                   limited authority over these plans.

          Possible additional benefits in Ohio plans
           Ohio law guarantees certain benefits. However your health plan
           may cover extra benefits. Therefore, there is a lot of variation.

Prescription drug coverage                         Well-child coverage
Ohio law does not require health plans             HMOs cover well-child care for all children.
to cover prescription drugs. Plans that do         Traditional plans that offer family coverage
provide this coverage can exclude a specific       must help pay for certain routine benefits for
drug or a specific class of drugs (example:        children, such as complete physical exams,
birth control pills). If your health plan covers   developmental assessments, anticipatory
prescriptions, it may have a formulary — a         guidance, lab tests and immunizations from
list of the drugs it will pay for.                 birth through age eight. Plans are not required
                                                   to pay more than $500 in benefits the first
It may be possible for you to get a drug           year, and no more than $150 each year from
that’s not on the plan formulary if your doctor    age one through age eight. As of age nine,
certifies the formulary drug will not treat your   this coverage is not required.
condition effectively or that it could cause a
bad reaction.                                      Mentally impaired or handicapped child
Mental health coverage                             Group policies for family members normally
All health plans in Ohio must provide              stop covering children who have reached the
coverage for the diagnosis and treatment of        range of 19 to 23 years old. But if your child is
biologically-based mental illness. Care must       mentally or physically impaired the coverage
be provided on the same terms and conditions       must be continued for as long as the child
as that of all other physical disorders, except    must depend on you for maintenance and
in limited circumstances.                          support.

A plan must also provide prescription drug
coverage for biologically-based mental illness
if prescription drugs are covered for physical
illness. Benefits must have the same copays,
deductibles and cost sharing requirements for
physical illnesses.

Employers and insurers may negotiate rates
of reimbursement and may establish provider
networks to deliver mental health services to
their insureds.

                                        For a list of authorized companies
                                       visit or call
                                      Consumer Services at 1-800-686-1526.

Domestic partner coverage                         Please note: pre-certification determines
Ohio law does not require health insurance        medical necessity, but does not guarantee
plans or private employers to provide             payment, even if surgery has been performed.
coverage for domestic partners and their          The insurance company could still deny
families. The law also does not prohibit such     payment based on factors the plan might not
coverage.                                         confirm during pre-certification, such as:
                                                   • Whether you are being treated for a
Hospitalization and emergency care                   pre-existing condition that your new policy
                                                     does not cover.
Except in emergency situations, most health
policies require you or your doctor to tell        • Discrepancies between information
the plan before you check into a hospital.           provided by your doctor during
Insurance companies call this procedure              pre-certification and your actual medical
pre-certification, and they use it to determine      records.
whether your hospitalization is medically          • Whether the patient was insured when
necessary. Your policy or benefits booklet           services were performed (maybe you did
should explain the procedure to follow and list      not pay last month’s premium or your child
a phone number you or your doctor can call.          was the patient but is not included under
                                                     the policy).
The company may also require notification
before you have outpatient elective surgery,      The plan’s pre-certification notice should
visit a specialist or have expensive tests such   make it clear what has and has not been
as a Computed Axial Tomography (CAT) scan         approved.
or Magnetic Resonance Imaging (MRI).
                                                  If you don’t agree with the company’s decision
                                                  you may have the right to appeal. See page

                                                  Pre-certification is never required in
                                                  an emergency. Ohio law defines medical
                                                  emergencies based on the actions a “prudent
                                                  layperson” (someone with little or no medical
                                                  knowledge or background) would take in such

         Choosing a plan / understanding your plan
            Before you choose a health plan or to understand the plan you have,
            check the policy’s details. Know how the plan defines the terms shown
            on this page to have an idea of your possible out-of-pocket costs.

Coinsurance                                       Deductible
The amount you pay for a covered service or       The amount you pay for medical bills before
treatment after the health plan’s deductible      your plan begins to pay. Normally, a larger
has been met. Coinsurance is usually based        deductible means a less expensive policy.
on a percentage.
                                                  Explanation of Benefits (EOB)
For example, you might pay 20 percent             A statement from your health insurer that
of hospital charges. If you use network           shows amounts it has paid and amounts it has
providers, you are responsible for 20 percent     not paid for a claim. If you want to challenge
of the eligible charges. Network providers        the company’s payments, it’s important to
have agreed not to bill for anything over the     make sure you get all the EOBs that apply to
approved amount.                                  the claim and keep them organized.

However, if you use non-network providers,        Lifetime maximum
the plan would pay its share up to the
approved amount only (this may be called          The maximum amount your health insurance
“usual, customary, reasonable” or UCR).           will pay for covered services during your
You are responsible for your coinsurance          lifetime. Look for the highest lifetime
percentage plus the difference between the        maximum you can find to guard against a
approved amount and the billed amount. The        catastrophic illness or accident.
difference can be significant.
                                                  Out-of-pocket maximum
Copayment                                         The amount of coinsurance / copayments you
A flat fee you pay for a covered health care      must pay yourself before your health plan
service or treatment. Certain types of plans,     starts paying 100 percent of your covered
including HMOs and some PPOs, require a           medical bills. This amount may or may not
copayment for each office visit to a doctor and   include the deductible and likely does not
often a larger copayment for emergency care.      include penalties and many out-of-network
Creditable coverage
Written proof of coverage from your former
employer or health insurer which you use          The amount you pay to the insurance
to get new insurance. Proof of creditable         company in exchange for providing coverage
coverage guarantees that any waiting period       for a specified period of time under a contract.
the new plan normally imposes before              Premiums are usually paid for a one-month
covering pre-existing conditions will be          period but can be scheduled for annual or
eliminated or reduced. This is important when     quarterly payment.
you change jobs (or insurance plans) and
need pre-existing conditions to be covered
right away.

        Helpful phone numbers and web sites
Organization                                   Phone                          Web site         
Ohio Dept. of Insurance                        1-800-686-1526        
  Consumer Services

Ohio Senior Health Insurance                   1-800-686-1578        
  Information Program (OSHIIP)

U.S. Dept. of Labor                            1-866-487-2365        

Ohio Dept. of Health                           (614) 466-3543        

Ohio Medicaid                                  1-800-324-8680        

Medicare                                       1-800-633-4227        

Ohio Public Health Departments                 (614) 221-5994        

Ohio Family Coverage Coalition                 1-800-634-4442        

                            What’s your situation?
        Choose the situation below that matches yours most closely,
      then turn to the pages shown to read helpful general information.

    • Getting individual health insurance ................................... pages 10-11

    • Young adults ..................................................................... page 12

    • Families ............................................................................ pages 13-15

    • Job change / Job loss ....................................................... pages 16-19

    • Surviving without health insurance ................................... pages 20-21

    • Running a small business or self-employed ..................... pages 22-23

    • How to appeal a decision by your health plan .................. page 24

               Getting individual health insurance
      If you cannot get health insurance through an employer or a government-
      sponsored program such as Medicare or Medicaid, you may be able to buy
      or access coverage for yourself and your family through individual coverage.

My job doesn’t offer a health plan. I’ve           Where can I find information on open
looked for coverage and no private                 enrollment? Is this a good option?
company will cover me. What can I do?
                                                    • Visit the Ohio Department of Insurance
 Here are some of your options:                       web site ( or
                                                      call the Department’s Consumer Services
 • Open enrollment: Ohio insurance                    Division: 1-800-686-1526.
   companies must hold open enrollment at           Open enrollment can be a good option,
   specified times each year. The coverage          depending on what else is available to you.
   is guaranteed issue. This means the
   company cannot deny you coverage.                If you’re eligible, health insurance through
   However, enrollment in any plan ends             open enrollment is guaranteed issue so you
   when the insurance company has taken             cannot be turned down. In general, people
   a required percentage of new insureds or         who apply through open enrollment have
   the specified enrollment period has ended.       pre-existing conditions. The premiums are
                                                    more expensive than health policies that are
 • Professional associations: You may qualify
                                                    medically underwritten.
   to join a professional, fraternal or civic
   association that offers health insurance to
                                                   I’m looking for part-time work. Will I have
   its members. Check in your city or county
                                                   health insurance?
   for such possibilities.
 • Government-sponsored: Medicare                   No employer is required to offer health
   provides health insurance to people age          insurance. However, you should be offered
   65 or older, and people under age 65 who         the same health benefits as any other
   have certain disabilities. Medicaid is health    employee if:
   insurance for people with limited income         • Insurance is offered by the employer, and
   and resources. You may qualify for one
                                                    • The group is between two and 50 people
   program or both.
                                                      and your normal work week is 25 hours or

                                Helpful contacts              
                                Ohio Dept. of Health ..................... (614) 466-3543
                                Ohio Public Health Departments .. (614) 221-5994
                                Medicare ....................................... 1-800-633-4227
                                Ohio Medicaid ............................... 1-800-324-8680
                                Ohio Dept. of Insurance ................ 1-800-686-1526

I’m getting a divorce / separating* from           I just found out I’m pregnant. Can I get
my partner and do not currently have a             health insurance?
job with insurance coverage. What are my
health insurance options?                           If you apply for individual coverage after
                                                    becoming pregnant — and the policy is
 If your ex-spouse has employer group               subject to medical underwriting — your
 health insurance and you are enrolled in           application will likely be rejected. This is
 that plan, you may have the right to continue      because the insurance company regards the
 group coverage through COBRA (see page             pregnancy as a pre-existing condition.
                                                    If you have an employer plan that includes
 Another option: you could convert the group        maternity benefits, see page 13.
 coverage to an individual policy offered
 by the same insurance company that fully           If you’re eligible, open enrollment may also
 insures your ex-spouse’s / ex-partner’s            be an option (see pages 17-19).
 group (see pages 17-18).
 * Neither same-sex or different-sex               I’m 50 years old and have been diagnosed
   domestic partners are eligible for COBRA.       with a disability. My employer does not
                                                   provide health insurance. Can I qualify for
I have never had health insurance and I            Medicare?
would like to purchase it. What are my
options?                                            In addition to people who are age 65 and
                                                    older, Medicare covers people with certain
 You can purchase insurance through:                disabilities who are not yet age 65.
 • Your employer, if health insurance               To find out if you are eligible:
   coverage is offered to employees and their
   families                                         • Call Medicare at 1-800-633-4227 or visit
 • A private carrier for an individual policy on
   your own                                         • For further assistance, call OSHIIP at
                                                      the Ohio Department of Insurance:
 • Professional associations                          1-800-686-1578

                                                   I’ve checked out the premiums and I truly
                                                   cannot afford health insurance right now.
                                                   What else can I do?

                                                    You may want to consider applying for
                                                    financial assistance. One possible option is
                                                    Ohio’s Medicaid program.

                                                    Medicaid provides basic health care
                                                    services for people with limited incomes and
                                                    children or disabilities. The Ohio Department
                                                    of Job & Family Services administers
                                                    Medicaid. Call your local county Department
                                                    of Job & Family Services or call the Ohio
                                                    Medicaid hotline to apply: 1-800-324-8680.

Visit for a list of authorized companies.                                11
                                     Young adults
  Growing up, many of us are covered under a parent’s health plan. Plans often cover
  children until college graduation. If you’re healthy, it should be easy to get your own plan.
I don’t have a lot of extra cash and I’m          I’m graduating from college this year. Can I
healthy. Wouldn’t it be a waste of money          keep the coverage I’ve had all along?
for me to buy health insurance?                     Normally, if you’ve been covered under your
 Now may be the best time for you to buy, for       parents’ health insurance policy while you
 the following reasons:                             were in college or by a plan offered through
 • If admitted to a hospital because of an          your college, the coverage stops when you
   accident or illness, you will be responsible     graduate. Also consider that many employer
   for the entire bill for your care unless you     plans have waiting periods before health
   already had health insurance.                    coverage starts.
                                                    Young adults who reach the limiting age
 • If you develop a condition that’s chronic
                                                    under such plans may extend coverage
   (long-lasting), insurance may not cover
                                                    under the Consolidated Omnibus Budget
   the condition unless you have owned the
                                                    Reconciliation Act — called COBRA — or
   policy for some period of time.
                                                    conversion (see page 17).
 • Once you have health insurance, the law
                                                    Other options:
   protects you from losing coverage due
   to illness. No company can cancel you            • Interim coverage may be offered by the
   unless you stop paying your premium.               college to graduates — check with the
I just landed my first job and the employer         • Catastrophic health coverage in the form of
is offering coverage, but the premium is              a short-term policy (see page 5)
expensive. Should I accept it?                      • A health discount card (see page 5)
 One of the best and least expensive ways to
 get and keep health coverage is through an       I’ve checked out the premiums and I truly
 employer. Not every company makes health         cannot afford health insurance right now.
 insurance available to its workers.              What else can I do?
 State and federal law can protect you from         You may want to consider applying for
 losing health insurance once you have it. If       financial assistance. One possible option is
 you get sick, change jobs or lose your job,        Ohio’s Medicaid program. Medicaid provides
 you can stay fully covered in a health plan.       basic health care services for people with
 Your coverage cannot be cancelled unless           limited incomes.
 you stop paying premiums.                          The Ohio Department of Job & Family
 For a more affordable option, ask if your          Services administers Medicaid. Apply at
 employer offers a flexible spending plan,          your local county Department of Job &
 such as a Health Savings Account (HSA).            Family Services or call the Ohio Medicaid
 You combine the account with a high-               hotline for information:
 deductible health plan, and fund the HSA           1-800-324-8680.
 with pre-tax dollars you can use to pay
 smaller medical expenses. The high-
 deductible plan covers large health costs.

 12              Visit for a list of authorized companies.
   Children are usually covered under a family health plan as long as they live
   with you. Many plans keep this coverage in effect until the kids graduate from
   college. When both parents work and they have two separate health plans,
   there may be situations when both plans can help pay medical bills for a child.

Our baby is due next month. How will my           We both work and have two separate
health insurance cover the charges for            health plans with family coverage. Which
delivery and after?                               plan covers the children?

 Review your coverage to find out how your         Ohio’s Coordination of Benefits (COB) rules
 health plan handles the costs. Consider           can allow you to use both health plans to
 all the costs that might apply to your            pay your children’s claims.
 situation: prenatal vitamins, prenatal and
 neonatal screenings and tests, emergency          One plan will be the children’s primary
 procedures, delivery and pediatric care.          insurance and pay first. The other plan will
                                                   be secondary and pay part or all of the
My partner recently gave birth to our baby         remaining amount. Ohio’s COB rules cover
daughter. Will my employer-sponsored               most situations when there are two health
health plan cover both my partner and              plans.
                                                   Make sure to follow all requirements (such
 Ohio law does not require nor prohibit the        as using network providers) for either plan; if
 coverage of domestic partners (same-sex           you don’t, the state’s COB rules will not help
 or different-sex) and their families by health    and both plans could deny your claim.
 plans or private employers. However, a child
 may not be denied enrollment because the         How long will my plan cover the children?
 child was born out of wedlock. Check with
 your Human Resources office for details on        Check with the plan. Coverage may last as
 your coverage.                                    long as the children live with you, graduate
                                                   from college or until the plan’s limiting age
My son is two weeks old. He’s covered              (commonly 19 and 23).
automatically under my health plan from
work, right?                                       In the case of a child who is diagnosed as
                                                   mentally retarded, the child continues to be
 No – you must let the plan know about the         an eligible dependent under your insurance
 new baby, normally within 31 days of the          policy regardless of age. Medicare may be
 birth. Consult with the employer or health        an option for children who are disabled.
 insurance provider regarding the notification
 requirements before your child is born. If
 you adopt, ask your employer or health plan                                    Continued     Z
 in advance about requirements for getting
 the coverage.

My dependent children are full-time                  If you are married and both spouses work
students. Are they still covered under my            and contribute to the household income,
plan?                                                consider disability insurance for both. Think
                                                     about having only one salary coming in and
 Usually, full-time students between the ages        plan accordingly.
 of 19 and 23 are covered by their parents’
 health plan. If your child attends an out-of-      My family is maturing. Are there good
 state college and your plan requires you to        reasons to adjust my coverage?
 use a network, you may need to find your
 child a separate health plan for coverage           If you have employer-sponsored coverage,
 other than emergency care. Ask the plan             you may want to consider annually whether
 if it has a network your student can use in         to alter elections or eliminate certain types
 the other state. If not, look for coverage by       of coverage that you may no longer need.
 working through the school or an insurance
 company authorized in that state.                   Ask your employer about making changes to
                                                     your coverage. Some group policies will not
I’ve heard of a program called SCHIP. Can            permit you to make any adjustments.
my kids qualify?                                     • If you have young children, you may want
                                                       preventive care benefits that include
 SCHIP stands for the State Children’s                 providing shots and “well visits” for the
 Health Insurance Program, a federal and               kids.
 state initiative to provide financial assistance
 to families who do not qualify for Medicaid.        • If you’ve decided not to have more
 For more information, please visit the Ohio           children, you may no longer want a policy
 Department of Job & Family Services at                that covers pregnancy-related services. or call 1-800-324-8680.            • Plans offered through health discount
                                                       cards may be an option, but they are
My agent talked with me about disability               not health insurance. Used properly,
insurance. Is it a good idea to buy a                  discount cards will save you money when
policy?                                                you receive health services from certain
                                                       doctors, dentists and other providers.
 That’s a decision only you can make. If a             Carefully research any discount card you
 working parent becomes disabled and the               consider. Discount cards cost less to have
 family loses income it may be difficult to            than insurance, but they provide only a
 manage. Weigh the cost you’d have to pay              discount on services; they do not pay for
 for disability insurance against the protection       services. Having a discount card does not
 it provides.                                          qualify as creditable coverage.
                                                     • Know your rights on keeping health
                                                       insurance (see pages 16-18). If you lose
                                                       your job, change jobs or decide to start
                                                       your own business, know the available
                                                       options to keep your family covered.
                                                     • You may want to consider whether long-
                                                       term care insurance makes sense for you.
                                                       You may want a certified financial planner
                                                       to help you weigh your options regarding
                                                       long-term care insurance.

What if I retire or get laid off before I turn
age 65? Will I be eligible for Medicare?           We’ve priced available plans and our
                                                   family truly cannot afford health insurance
 Medicare covers people who have paid              right now. What else can we do?
 into the system for a specific period of time.
 Others may purchase coverage. You must              You may want to consider applying for
 be at least age 65 to qualify or be under           financial assistance. One possible option is
 age 65 with certain disabilities. People who        Ohio’s Medicaid program.
 retire or lose employer coverage before age
 65 should consider buying a health plan to          Medicaid provides basic health care
 cover the period of time before they qualify        services for people with limited incomes and
 for Medicare.                                       children or disabilities. The Ohio Department
                                                     of Job & Family Services administers
 If you are planning to retire early, talk with      Medicaid. Apply at your local county
 your employer’s human resources staff. Find         Department of Job & Family Services or call
 out if you are eligible for health insurance in     the Ohio Medicaid hotline for information:
 the employer plan under one of the methods          1-800-324-8680.
 established by law to help you stay covered
 (COBRA, continuation or conversion). See
 pages 16-19.

 Your premium will be more expensive than
 when you worked. In addition, the employer
 can renegotiate its group health insurance
 contract at any time, which can cause
 changes to your premium or terminate the
 coverage. However, you are more likely to
 get a better rate in the employer plan than if
 you have individual coverage.

 If your COBRA benefits run out and you’re
 still not yet eligible for Medicare, you may
 want to consider a conversion policy (see
 page 17).

        Helpful contacts             
        Ohio Family Coverage Coalition ...... 1-800-634-4442
        Ohio Public Health Departments ..... (614) 221-5994
        Medicare .......................................... 1-800-633-4227
        Ohio Medicaid .................................. 1-800-324-8680
        Ohio Dept. of Insurance ................... 1-800-686-1526

                             Job change / Job loss
    Keeping health insurance can be guaranteed by state and federal law. Once covered,
    you cannot lose coverage because you have an accident or get sick. Your health
    insurance cannot be cancelled unless the employer stops paying the premium for
    your employer-sponsored plan, or you stop paying the premium for a plan you own.
    In general, if you leave a job where you participated in an employer group health
    plan, you may be able to stay covered no matter what happens next. Keeping health
    insurance is your right. Any new plan may be different and will likely cost you more,
    but if you follow the rules, you can keep your family covered.

I’m leaving a job with employer group               • If you (or a family member) are pregnant
coverage for a new job that also provides             when you switch jobs, the new plan
group coverage. What are my rights?                   covers the pregnancy only if the new plan
                                                      includes maternity coverage.
 You have rights under the Health Insurance
 Portability and Accountability Act (HIPAA).        • The new plan may have a waiting period
 HIPAA reduces or eliminates the period you           before you can enroll. Talk with the new
 would otherwise have to wait for the new             employer about specifics.
 plan to cover pre-existing conditions.             If the new plan is through an HMO:
 HIPAA applies if you have an employer              • The plan may have an “affiliation period”
 health plan, leave for a new job and the new         which could delay your coverage for a
 employer offers health insurance.                    maximum of 90 days after you submit the
                                                      enrollment form.
 ANY plan your new employer offers:
                                                    • No pre-existing condition waiting period is
 • Must include all family members who meet           allowed. All benefits must be covered the
   the new plan’s eligibility requirements.           day coverage goes into effect.
 • Cannot reject you or charge you higher           • Maternity must be covered if the plan is full
   premiums because of a family member’s              service.
   health problems.
 • May offer a special enrollment period           I’m leaving a job with employer group
   if you add a new dependent due to               insurance for a job that does not offer a
   marriage, birth, adoption or loss of other      health plan (or to become self-employed).
   coverage. Any family member can join            — OR — I’ve been laid off from a job with
   during a special enrollment period without      employer group insurance. What are my
   having to wait for coverage of pre-existing     options?
 • May cost you more than the old plan.             Generally, you will be able to choose from
                                                    two options...
 If the new plan is through a traditional health
                                                      Continuation of the group benefits:
 insurance company:
                                                      Temporary coverage that lasts no less
 • Enroll within 63 days after your previous          than six months.
   coverage ends in order to use your
                                                      Conversion to an individual policy /
   creditable coverage (see page 18). By
                                                      Purchasing your own individual policy:
   applying creditable coverage, you reduce
                                                      Permanent coverage that lasts as long as
   any period of time the plan requires before
                                                      you pay premiums.
   it covers your pre-existing conditions.
Continuation of group coverage / COBRA           • 36 months if you were insured through
You have the right to temporarily continue         your spouse’s job or parent’s job and that
group coverage if you lose a job with              individual becomes eligible for Medicare,
employer-sponsored health insurance. The           dies, or you lose your dependent status;
number of employees at the job you left will     • The employer goes out of business or
determine how it may work.                         stops offering an employee group plan;
Ohio’s continuation law                          • You fail to pay the premium.
If your employer has two to 20 workers, you
can continue under the ex-employer’s group       Once COBRA ends you can apply within 31
coverage for six months, if you:                 days to convert (see below) to an individual
                                                 policy provided by the group’s insurer under
• Were covered for three months prior to         Ohio’s Basic or Standard plan, unless the
  termination,                                   employer is self-insured.
• Are eligible for unemployment,
                                                 Ask the human resources office for a booklet
• Pay the plan’s full cost,                      on COBRA. Or contact the U.S. Department
• Are not eligible for Medicare, and             of Labor, Employee Benefits Security
• Apply within 31 days of losing group           Administration at 1-866-444-3272.
                                                 Conversion to an individual policy /
Federal continuation law: COBRA                  Purchasing your own individual policy
If you leave a company with 20 or more           If you lose a job with employer-sponsored
employees, you can temporarily continue          health insurance, you may be eligible for
the ex-employer’s group coverage under           permanent individual coverage that will last
a federal law known as the Consolidated          as long as you continue to pay premiums.
Omnibus Budget Reconciliation Act
                                                 HIPAA, the same federal law that allows
                                                 you to maintain coverage when you change
COBRA does not apply to plans sponsored          jobs, also established two full-service
by the federal government and some               individual health plans available to people
church-related organizations.                    losing employer group insurance. These
                                                 plans are called Basic and Standard.
The employer must notify you of your rights
under COBRA within 30 days after you leave
the group. Once you’re notified, you have an
                                                                             Continued      Z
additional 60 days to apply for coverage.
You will be responsible for the full premium
plus two percent for administrative fees.
Coverage under COBRA is temporary and
ends after:
• 18 months, in most cases;
• 29 months if you become eligible for Social
  Security disability during the first 60 days
  of COBRA continuation;

When you move from employer group                coverage through a certificate from your
coverage to an individual plan, it helps         ex-employer or its health plan.
to know if you are a “federally eligible
individual” (or FEI) under HIPAA. In             You have creditable coverage if you were
general, a person with FEI status has had        under any plan listed here:
no lapse in health coverage.                     • A group health insurance plan
See the list of qualifications below; you must   • Medicare or Medicaid
meet all of them to be a federally eligible
individual.                                      • TRICARE

Depending on your FEI status, coverage           • Indian Health Medical Program
under the Basic or Standard plans may be         • A state health risk pool
immediate. The period of time before the         • A health plan under chapter 89 of title 5,
new plan covers pre-existing conditions may        USC
also be reduced.
                                                 • A public health plan
You cannot be turned down for coverage
                                                 • A health plan under section 5(e) of the
due to your health, but a plan can reject
                                                   Peace Corps Act
you if it has already reached its annual
enrollment limit.                                • A state children’s health insurance program
You qualify as an FEI only if you meet all of
the following conditions:
                                                 Conversion to an individual plan from the
• Have had 18 months of creditable               employer’s insurance company
  coverage (see below),                          Through HIPAA, Ohio has two individual
• Were most recently covered by an               health plans called Basic and Standard. You
  employer group,                                can convert your coverage to any Basic or
• Were not terminated from your group plan       Standard plan offered by the employer’s
  due to premium nonpayment or fraud,            insurance company, unless the employer is
• Obtained coverage by midnight of the 63rd
  day after your previous coverage ended,        You must have had continuous coverage
• Are not eligible for Medicare, Medicaid or     for one year prior to conversion. If you
  other group coverage,                          apply within 31 days of leaving the group,
• Have exhausted all continuation of benefit     you cannot be turned down for coverage
  options (e.g., COBRA) and                      due to your health. The new plan may cost
                                                 more and may not have the same benefits.
• Do not have any other health insurance.        You can keep the policy as long as you pay
Creditable coverage is proof that you were       premiums.
covered under your old plan. It reduces —        You have conversion rights if you have FEI
or eliminates — the period of time a new         status and:
plan can make you wait before it pays for
your or your covered family member’s pre-         • You leave the employer, or
existing conditions.                              • You are a covered family member of an
You get credit for how long you were with           insured who has died, or
the old plan; the new plan must reduce your       • You reach the age limit for coverage
pre-existing condition waiting period by an         under your parent’s group or
equal amount of time. You prove creditable        • You divorce or separate from the insured.

Purchasing an individual plan from any          I’m leaving a company that self-insured.
health insurer                                  What are my rights and options to secure
The rules for buying your own policy from       health insurance?
the individual health insurance market           Your options will generally include temporary
depend on whether you are a federally            continuation of the group benefits (see
eligible individual, or FEI (see page 18).       COBRA, page 17), or purchasing individual
If you qualify as an FEI                         coverage on your own (see pages 17-18).
                                                 Contact the U.S. Department of Labor with
• No insurance company offering individual       questions: 1-866-487-2365.
  coverage can reject your application for
  the Basic or Standard plan because of         I have been fired and no longer have
  your health status.                           health insurance. What are my options?
• Pre-existing conditions cannot be              If you have been fired because of gross
  excluded.                                      misconduct — and are not eligible for
• Conversion is an option. Your former           unemployment — continuation of group
  employer’s insurance company must              health insurance coverage is not an option.
  accept your application to convert your        See “Purchasing an individual plan from any
  group coverage to an individual plan (see      health insurer” (above) for details about your
  pages 17-18). However, any other insurer       options for individual coverage.
  can reject your application if the plan has
  reached its open enrollment limit.            I’ve checked out the premiums and I truly
                                                cannot afford health insurance right now.
If you do not qualify as an FEI                 What else can I do?
• Open enrollment may be an option. Ohio         You may want to consider applying for
  insurers must hold open enrollment to          financial assistance. One possible option is
  give individuals who do not qualify for FEI    Ohio’s Medicaid program.
  status an opportunity to purchase health
  insurance.                                     Medicaid provides basic health care
                                                 services for people with limited incomes and
• You cannot be rejected due to poor health,     children or disabilities. The Ohio Department
  but the policy may be underwritten.            of Job & Family Services administers
• However, any insurer can reject your           Medicaid. Apply at your local county
 application if the plan has reached its open    Department of Job & Family Services or call
 enrollment limit.                               the Ohio Medicaid hotline for information:

          Helpful contacts            
          U.S. Dept. of Labor .......................... 1-866-487-2365
          Ohio Dept. of Health ........................ (614) 466-3543
          Ohio Public Health Departments ..... (614) 221-5994
          Ohio Medicaid .................................. 1-800-324-8680
          Ohio Dept. of Insurance ................... 1-800-686-1526

                Surviving without health insurance
      More than 12% of Ohioans (or over 1.3 million people) are uninsured today
      and that number continues to grow. Many Ohioans are also underinsured.
      Reasons Ohioans are uninsured include all or more of the following: cost,
      access and / or exclusion due to one or more health conditions.
      Ohioans who lack adequate health coverage may find help through certain
      Ohio organizations which provide services such as free or sliding scale
      clinics, community health centers, medications, supplies, preventative
      care classes and other networking information. Also, please contact the
      Ohio Family Coverage Coalition (
      famcovcoal.html) for a detailed brochure.
I am diabetic and, even though my               Where can I find affordable prescriptions
income is limited, I don’t qualify for          since I have no insurance?
Medicaid. Where can I get testing supplies,
discounted medications or insulin?               The Columbus Public Health Department
                                                 (614-645-6248) has compiled a list to help
 You may want to try the following: explore      with prescription costs. Their list includes
 Disability Medical Assistance (through the      programs such as Prescription Access,
 Ohio Association of Free Clinics, your local    Prescription for Good Health, Ohio’s Best
 Department of Public Health and ODJFS);         Rx, Rx for Ohio and Rx Outreach.
 contact nonprofit associations such as the
 Central Ohio Diabetes Association (www.         Check with your local health department or the Ohio United Way        about a similar list for your area (Association
 (; and contact pharmaceutical       of Health Commissioners: 614-221-5994 or
 companies directly to see if they have any
 prescription discount programs.

What benefit do local chapters of                 As a person with a limited income who
associations (such as those dealing with          doesn’t qualify for Medicare, Medicaid,
cancer, diabetes, lung, kidney, etc.) have        employer or individual coverage, where
for uninsured or underinsured people?             can I find adequate and affordable health
                                                  care assistance?
 Associations may provide you with
 resources (discount prescription                    You can get the brochure “Ohio Health
 information), services (access to doctors) or       Care Safety Net: A description of public
 educational materials (nutritional classes)         and private programs” from the Universal
 which may be subsidized or free. Check              Health Care Action Network of Ohio
 the association web sites or call them with         (UHCAN Ohio) and the Ohio Family
 questions. You can also get information on          Coverage Coalition. Visit www.uhcanohio.
 your local associations from the United Way         org/coalitions/famcovcoal.html or call
 of Ohio.                                            1-800-634-4442.

                                                     In addition to providing details about
                                                     Medicaid and Medicare, the brochure
                                                     addresses issues about medical assistance
                                                     for various groups of people, including
                                                     refugees, undocumented persons,
                                                     noncitizen immigrants, veterans, children
                                                     and persons with disabilities. The brochure
                                                     also provides contact information for health
                                                     departments all over Ohio (;
                                                     information on oral, vision and behavioral
                                                     health resources, subsidized care at
                                                     local hospitals, community health centers
                                                     ( and free clinics (www.

       Helpful contacts             
       Ohio Family Coverage Coalition ...... 1-800-634-4442
       Ohio Public Health Departments ..... (614) 221-5994
       Medicare .......................................... 1-800-633-4227
       Ohio Medicaid .................................. 1-800-324-8680
       Ohio Dept. of Insurance ................... 1-800-686-1526

         Running a small business or self-employed
          Health insurance is extremely important to most employees and can
          be a powerful benefit in recruiting and retaining the best workers.
          Cost and availability are key issues employers have to consider.

My business is small but growing. Can I          I’ve priced group coverage and it’s
offer my workers a group health plan?            expensive. What are my other options?

 It is possible. Your premium will be based on    A Health Savings Account (HSA) may be
 how many employees participate and their         another type of health insurance you could
 health status. You can negotiate                 offer your workers. The account works with
 directly with an insurance company or hire       a qualifying high-deductible health plan to
 an insurance broker to identify a plan.          provide coverage. The HSA is used to pay
                                                  routine expenses, and the high-deductible
 Insurance companies offer small and              plan is used to pay more significant
 large group coverage. Comparison                 expenses. The high-deductible plan can
 shop traditional insurance, Preferred            be through an HMO, PPO or traditional
 Provider Organization (PPO) and Health           insurance.
 Maintenance Organization (HMO) plans for
 coverage that suits you at a cost to fit your    The HSA is funded with pre-tax dollars to
 business model.                                  pay eligible health care expenses including
                                                  insurance policy deductibles, copayments
                                                  and out-of-pocket medical expenses.
                                                  Employers can establish HSAs for their
                                                  workers; individuals can set them up for
                                                  themselves as well. Required coverage
                                                  amounts, out-of-pocket expense limits and
                                                  annual contribution limits may apply.

                                                  Employer and employee contributions,
                                                  earned interest and amounts used to pay
                                                  eligible expenses are not taxed. You may
                                                  take an HSA with you when you leave your

            For a list of authorized companies
           visit or call
          Consumer Services at 1-800-686-1526.

I’ve heard of small business alliances. How       Can you offer any other health insurance
can they help?                                    shopping tips for small business owners?

 A health care alliance is a cooperative of         • Before purchasing any insurance, interview
 small businesses that band together to form          several licensed insurance agents who
 a larger group in order to make coverage             specialize in serving the health insurance
 more affordable. Any employer group                  needs of small businesses.
 with fewer than 500 employees, and that             • Before selecting a health plan, consider
 meets the alliance’s membership criteria             an employee survey to find out what kind
 (examples: being a member of a chamber               of coverage is particularly important to
 of commerce or a member of a certain                 them.
 industry) can join. Employers who join such
 alliances may be entitled to certain tax            • Understand the factors that can affect the
 benefits.                                            cost of your small group health premiums.
                                                     • Visit or call the
 Most areas in Ohio have one or more small
                                                      Department’s Consumer Services Division
 business alliances. To get a current list call
                                                      at 1-800-686-1526 to determine if an agent
 the Department of Insurance Consumer
                                                      or company is licensed to do business in
 Services at 1-800-686-1526 or go to our
                                                      the state
 web site (
                                                    • Call Consumer Services if you have any
                                                      other insurance questions.

           Helpful contacts             
           U.S. Dept. of Labor .......................... 1-866-487-2365
           Ohio Dept. of Health ........................ (614) 466-3543
           Medicare .......................................... 1-800-633-4227
           Ohio Dept. of Insurance ................... 1-800-686-1526

      How to appeal a decision by your health plan
      You may not always agree with decisions your health plan makes regarding
      your care. If such a dispute occurs, you can appeal the plan’s decision.

My health plan refuses to pay for a                Does my case qualify for an external
treatment I need. What can I do?                   review? What is the review process?
 Review your policy or benefits booklet for         Appeals denied through a health plan’s
 information on filing a complaint and / or an      internal process generally may qualify for
 appeal. You can also contact the company’s         external review with an IRO when:
 customer service office. Most companies
                                                    • The insurance company has determined
 have toll-free telephone numbers.
                                                      the service you want is not medically
 Ohio health plans have an internal process           necessary,
 for appeals. If you are not satisfied with the
                                                    • Your provider documents that the service
 way your claim was treated, you can request
                                                      (and all care related to the service) will
 an appeal.
                                                      cost you more than $500 if not covered,
How can I get an appeal started?                      and
 The plan’s internal appeal process is your         • You request external review within 60
 first step if you disagree with a decision your      days of being notified about the internal
 insurance company makes. Your policy has             decision.
 specific details on your health plan’s review
                                                    The independent review organization
 process. You can appeal any decision the
                                                    conducts each review through a clinical
 insurance company makes.
                                                    peer... that is, a medical professional who
 Contact your plan to begin an appeal. Some         has credentials appropriate to the case.
 carriers will accept a telephone appeal,           IROs are accredited by the Ohio Department
 while others require a written appeal. The         of Insurance and are not affiliated with any
 carrier must notify you in writing of its final    insurance company.
 decision within a specific time frame. You
 must complete the plan’s appeals process           The insurance company is required to pay
 before you can move to the next step.              all external review fees. Once the IRO has
                                                    the needed information, it must make a
What if the plan rejects my appeal?                 decision within 30 days. Decisions must be
 It depends. Once you’ve completed the              expedited if your health condition requires it.
 plan’s internal appeal process:
                                                    The IRO decision is binding on the health
 • If you have been told the service you            plan, so if the IRO finds that the service or
   requested is not covered under your              treatment should be covered, the insurance
   policy, you can ask the Ohio Department          company must pay for it.
   of Insurance to review this decision.
 • If the plan denies, reduces or terminates       How do I request an external review from
   a service or treatment because the plan         an IRO?
   determines the service or treatment is not       Request the review directly from your health
   medically necessary or experimental /            plan. See your contract or evidence of
   investigative, your case could be eligible       benefits for instructions.
   for an external review with an independent
   review organization (IRO).

           About the Ohio Department of Insurance
The Ohio Department of Insurance is one           Provider complaints
of the state’s largest consumer protection        Healthcare providers can submit a complaint
agencies. Our professionals offer free            by visiting the Department of Insurance
and objective information to help Ohioans         web site ( and
understand insurance and resolve certain          completing a Prompt Pay Complaint Form.
issues they may experience.                       Providers should follow all contract grievance
                                                  and appeal procedures before filing a
Filing a consumer complaint with the Ohio         complaint with the Department.
Department of Insurance
If you believe your health plan is failing to     About the regulatory authority of the Ohio
pay a claim or denying a service or treatment     Department of Insurance
that appears to be covered in your contract,      In most cases, the Ohio Department of
and you’ve completed any internal process         Insurance is authorized to make sure covered
the plan has to review such appeals, contact      people get benefits as written in their health
the Ohio Department of Insurance Consumer         policy. In the case of “self-insured” plans,
Services Division.                                however, Department of Insurance authority
                                                  may be limited. See page 3 for general
       Call Consumer Services:                    information on self-insured plans.
                                                  The Ohio Department of Insurance cannot
Before the Department can investigate, you        make decisions about medical necessity. See
must submit a written complaint. We can mail      page 24 on appealing plan decisions.
you a copy of our form to complete and return
or you can use a copy of the form printed in      The Ohio Department of Insurance does not
this guide, across from page 28.                  regulate the benefit or cost structure of group
                                                  plans. As long as the contract meets Ohio’s
You can also visit the Department web site        legal requirements, contract details are up to
( to download the           the policy owner. Such factors can include
form or complete our online form.                 your right to extra benefits or the premium
                                                  amount you pay for coverage. See pages 6-8.
We will send the insurance company a copy
of the complaint, and ask them to resolve it or   The Ohio Department of Insurance does not
explain its position. Insurance companies are     set insurance company premiums or rates.
required by law to respond to the Department.     Each insurance company calculates its own
We will review all the facts to make sure the     premiums. For true individual policies, the
carrier has followed its contract with you, and   Department reviews the rates and makes sure
that it has complied with insurance rules and     the insurance company meets Ohio’s legal
laws.                                             requirements.

                                                  Please note: most “individual” policies sold
                                                  today are issued through an association
                                                  group. Insureds receive a certificate instead of
                                                  a policy. Group rates are not regulated by the
                                                  Department of Insurance.

                                      Glossary of terms
Approved Amount - The dollar amount on which           Copayment (coinsurance) - A specified dollar
an insurance company bases its payments and            amount or percentage of covered expenses
your copayments. This may be less than the billed      which an insurance policy or Medicare requires a
charge.                                                beneficiary to pay toward eligible medical bills.

Beneficiary - A person who receives the benefits       Covered Services - Services for which an
of any insurance plan or policy.                       insurance policy will pay.

Benefit Maximum - The most a health insurance          Deductible - A specified dollar amount of covered
policy will pay for a specified loss or covered        medical expenses which the beneficiary must pay
service. The benefit can be expressed as either a      before an insurance policy will pay.
period of time, a dollar amount or a percentage of
the approved amount. Benefits may be paid to the       Enrollment Period - Period during which people
policyholder or a third party.                         can enroll for an insurance policy, Medicare or
                                                       Health Insuring Corporation / Health Maintenance
Benefit Period - The time for which benefit            Organization (HMO) benefits.
payments from an insurance policy are available.
A policy may include different benefit periods for     Exclusion - A procedure or condition which an
different kinds of treatment or services.              insurance policy does not cover.

Billed Charge - The dollar amount a health care        Experimental - Medical treatment which is not
provider bills to a patient for a particular medical   generally accepted within the medical profession.
service or procedure.                                  Insurance policies sometimes do not cover
                                                       these procedures. Companies often disagree
Certificate Holder - An employee or other insured      with doctors on whether a specific procedure or
named under a group health insurance policy.           treatment is experimental.

Chronic Condition - A continuous or prolonged          Explanation of Benefits (EOB) - A statement
illness or condition. Examples: asthma, diabetes,      from an insurance company showing which
varicose veins.                                        payments have been made on a claim.

Claim - A request for payment for services.            Federally Eligible Individual (FEI) - A person
                                                       who meets federal standards for continuing or
COBRA (Consolidated Omnibus Budget                     obtaining health care coverage under HIPAA.
Reconciliation Act) - Federal law requiring
that workers who end employment for specified          Fee For Service - Traditional insurance that
reasons have the option of continuing group            does not place restrictions on which doctors you
insurance through the employer for a limited           can use. The insurer pays a percentage of the
period of coverage (usually 18 months; can be 29       expense you incur.
months or 36 months).
                                                       Free Look - The period during which you may
Conditionally Renewable - An insurance policy          reconsider the purchase of an insurance policy,
that the company will renew with each premium          cancel and get a full refund. Individual health
payment, as long as you meet certain conditions.       policies have a free look of at least 10 days;
                                                       Medicare supplement and long-term care policies
Coordination of Benefits (COB) - Procedures            have 30-day free look periods.
used by insurers to avoid duplicate payments
when a person is covered by more than one

Grace Period - A set period after an insurance        Insured - An individual or organization protected
policy premium payment is due, during which the       by an insurance policy.
policyholder may still make a payment. The policy
remains in effect during the grace period.            Lifetime Maximum - The total amount a policy
                                                      will pay for covered expenses during an insured’s
Group Insurance - A contract between an insurer       lifetime.
and an employer or association.
                                                      Long-term Care (LTC) insurance - Insurance
Guarantee Issue - A type of health insurance          that pays for care given in a skilled nursing facility,
policy that is issued regardless of health.           adult care facility or at home. Covers chronic
                                                      medical conditions and helps with activities of
Guaranteed Renewable - An agreement by an             daily living.
insurance company to insure a person for as long
as premiums are paid.                                 Loss - The basis for a claim under an insurance
                                                      policy. In health insurance, loss can refer to
HIPAA (Health Insurance Portability and               medical expenses (or, in a disability policy, loss of
Accountability Act) - Federal law that guarantees     income) resulting from illness or injury.
health care plan eligibility for people who change
jobs, if the new employer offers group insurance.     Loss Ratio - The dollar amount an insurer pays in
                                                      claims compared to the amount it collects from all
Health Insuring Corporation (HIC) - A term for        customers in premiums. Loss ratio is usually the
certain managed care insurers in Ohio, including      percentage of each dollar collected in premiums
all HMOs. The Department of Insurance regulates       which is paid out in claims.
                                                      Medically Necessary - Treatments or services
Health Maintenance Organization (HMO) - A             an insurance policy will pay for as defined in the
managed care plan that provides comprehensive         contract. Check your policy for specific language
care for a monthly premium. Office visits with your   defining medically necessary.
doctor usually require a copayment. You must
live in an HMO’s service area to join. You usually    Multiple Employer Welfare Arrangement
must use the plan’s providers and facilities before   (MEWA) - An organization of employers who join
the plan will pay its share for covered health        together as a group to provide health care benefits
services.                                             for their employees. Ohio law requires a MEWA
                                                      to either buy an insurance policy that covers
Health Savings Account (HSA) - A savings              its members’ employees, or meet the financial
fund that allows the insured to pay for medical       standards for an insurance company.
expenses with pre-tax dollars. Such an account
must be paired with a high-deductible health plan.    Open Enrollment - A period of time when new
                                                      subscribers may enroll in a health insurance plan
High-deductible Health Plan - A health plan for       regardless of their health.
which you accept a more expensive deductible.
Because you take more risk, you pay a lower           Out-of-State Group Policies - A group policy that
premium.                                              is sold outside of Ohio. Example: you live in Ohio
                                                      and are covered by a policy your group purchased
Hospital Indemnity Policy - Pays a fixed dollar       in Indiana. The policy may be regulated by Indiana
amount for each day you are in the hospital,          law rather than Ohio law.
regardless of actual hospital bills.

Inpatient - A person who has been admitted to
a hospital or other health care facility to receive
                                                                                         Continued       Z
diagnosis, treatment or other health services.

Outpatient - A patient who receives care at a           Rider - A legal document that modifies an
hospital or other health facility without being         insurance policy. Riders may either extend
admitted to the facility. Outpatient care also refers   or decrease benefits, or add or exclude specific
to care given in other locations such as outpatient     conditions.
                                                        Secondary Payer - Applies only when you
Policy Benefit Limits - Some plans limit the total      have more than one health insurance plan. The
amount the policy will pay over the course of your      secondary payer is the plan whose payments
lifetime. Once your medical bills have reached the      cannot be made until another plan (the primary
company’s set limit, you can no longer use your         payer) has processed the claim. Also see
policy. HMOs cannot have a lifetime dollar limit on     Coordination of Benefits.
covered basic health care services, although they
may have annual limits on services which are not        Self-insured Plan - An organization (usually an
basic healthcare services.                              employer) that pays health care costs out of the
                                                        organization’s own pocket.
Pre-existing Condition (Pre-ex) - Health
conditions or problems that were diagnosed or           Short-term health insurance - Health insurance
treated before health insurance was purchased.          that generally provides coverage for no longer
Check your policy for specific language defining        than a year. Because you cannot carry eligibility
pre-existing conditions.                                from prior coverage to a short-term policy, a
                                                        short-term health plan never covers pre-existing
Pre-certification - A requirement that you obtain       conditions. College alumni associations may offer
the insurance company’s approval before a               this option to recent graduates.
medical service is provided. If you fail to follow
the pre-certification procedures the company            Specific Disease Policy - A health insurance
may reduce or deny claim payment. Please note:          policy that covers the expenses incurred only for a
getting pre-certification does not guarantee claim      specific disease named in the policy. Also known
payment. Also called Utilization Review.                as Dread Disease policy. The most common type
                                                        is cancer insurance.
Primary Payer - Health insurance policy that pays
first when a person is covered by more than one         Underwriting - The process by which an insurer
insurance plan.                                         establishes and assumes risks. An insurance
                                                        company is underwriting when it agrees to insure
Preferred Provider Organization (PPO) - An              you because you are healthy or rejects your
insurance company plan based on a network of            application because you have a history of health
providers. You may be able to see any doctor            problems.
without a referral, although the plan will pay less
if the doctor is outside its network. You normally      Usual, Customary and Reasonable (UCR) - The
have a copayment for office visits to a network         dollar amount a company has determined to be
doctor. Copayments may vary; deductibles,               the appropriate charge for a particular medical
coinsurance and out-of-pocket maximums may              service. Each company sets its own UCR. It is
also vary, depending on the plan.                       often less than the billed charge.

Provider - A person or organization that provides       Waiting Period - The time you must wait before
medical services, such as a doctor, hospital, x-ray     group health insurance from a new employer goes
company, home health agency, pharmacy, etc.             into effect.

                                                        Waiver - An amendment to a health insurance
                                                        policy that excludes coverage for a specific

Consumer Services Division
50 W. Town St., 3 Fl.
                                           Ohio Department of Insurance
                                                     Ted Strickland – Governor
Suite 300
                                                     Mary Jo Hudson – Director
Columbus, Oh 43215
(614) 644-2673
(800) 686-1526                                 Consumer Complaint
Fax (614) 644-3744

Please note: This complaint form, all documents you send us, and any document received by our office as a result of
handling your complaint may be a public record, subject to Ohio’s Public Records Act. This law requires all public records
to be available for inspection by anyone, upon request. WARNING: All documentation we receive will be imaged,
then destroyed. Make copies of your documents and send the copies to us. Do not send original records.

If completing this form by hand, please use black or blue ink. DO NOT USE PENCIL.
Address                                                                County
City                              State                             Zip                     Phone
Insured’s Name (if different)
Name of Insurance Company
Policy or ID Number (if your ID is your Social Security Number, give only the last four digits)
Group or Employer Name
Name and Address of Agent/Broker (if involved)
Type of Insurance (check only one)          Auto                                 Home                            Health
                                            Credit Life/Credit Disability        Life                            Dental
                                            Disability Income                    Annuity                         Other
Small Business Owners: Name of business
If you are a small business employer, please check here
Type of Problem (check one or more):               Claim dispute or delay                  Claim denial
     Cancellation or non-renewal                   Payment not credited                    Policy not received
     Cash surrender/cash value not received        Misrepresentation                       Open enrollment           Other
If this is a health insurance complaint, please attach the most recent response you received from the company.
Health Insurance Claim #                                                    Date of Service
If the problem is a claim dispute regarding auto, home, or other property Insurance:
Date and Location of Accident or Loss                                       Claim #
Briefly describe your complaint. Please attach copies of all relevant documents.

If you need more space, please attach additional sheets.
How would you like to see your complaint resolved?

Please sign and date: To the best of my knowledge the above statement is correct. I understand that a copy of this form
and any attachments may be sent to the insurance company or agent involved. I authorize the insurance company to
release all the medical records relating to this complaint to the Ohio Department of Insurance, and I authorize the Ohio
Department of Insurance to release medical records relating to this complaint to the insurance company or agent as
necessary in order to resolve this complaint. I represent that I have the proper authority to execute this release.

Your Signature                                                                                 Date

                             Accredited by the National Association of Insurance Commissioners (NAIC)
INS1005 (Rev. 4/2008)                                                                                                 Page 1 of 1
                 To request consumer publications
         or ask questions about insurance, please call the
          Ohio Department of Insurance consumer lines:
                 Medicare issues... 1-800-686-1578
           Other types of insurance...1-800-686-1526
                             Fax (614) 644-3744
              For many Department services and
        publication updates, please visit our web site...

        The Ohio Department of Insurance is an Equal Opportunity Employer.

                                                                  Presorted Std
                                                                  U.S. Postage
50 W. Town St. — Suite 300
                                                                 Columbus, Ohio
Columbus, Ohio 43215
                                                                 Permit No. 4892

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