Articles Posted in Health Insurance

Millions of Americans have lost jobs — and often the health coverage that came with those jobs. Millions of Americans had their work hours reduced or have received drastic pay cuts, so monthly premiums that may have been manageable before are now out of reach. It is important to understand your options and take action right away, so you don’t have gaps in health insurance coverage.

First, find out when your coverage is ending. You may have coverage until the end of the month you’re laid off or longer, depending on your employer. After your employer’s coverage ends, you can usually continue your employer’s coverage (but pay much higher premiums) or buy a policy on your own. Your best choice depends on each policy’s premiums, coverage, provider network – and what medical needs you and/or your family members have.

Here are some things to consider when evaluating your options.

On April 8, 2020 Kantor & Kantor Partner Elizabeth Hopkins and Karen L. Handorf of Cohen Milstein, filed a friend-of-the court brief in the Supreme Court for Phyllis Borzi and Dan Maguire, two former, high-ranking Department of Labor officials.

The brief supports a number of States that successfully challenged a newly-enacted federal regulation, which runs contrary to the requirement in the Affordable Care Act (ACA) that women in healthcare plans be provided free access to preventive health services.

Under the challenged regulation, virtually any employer may simply disregard the ACA requirement that healthcare plans provide cost-free contraception for women enrolled in such plans, and thereby prevent enrolled women from receiving this congressionally-mandated preventive health service.

On March 30, 2020, California Insurance Commissioner Ricardo Lara and the California Department of Insurance (“CDI”) directed health insurance companies to increase access to services delivered via telehealth during the COVID-19 state of emergency.

The agency said that increasing the availability of telehealth will “lessen the strain on the supply chain, reduce the need to use scarce stocks of provider personal protective equipment and protect the ability of the healthcare workforce to provide care by limiting physical exposure to potential sources of infectious disease,” the notice states.

To support expanded telehealth, CDI said insurers should allow all network providers to use all available modes of virtual care delivery, including video and telephone-based communication. Insurers are also required to reimburse telehealth services costs at the same rate as in-person office visits, effective March 30, 2020.

In addition to dealing with short term disability benefits, long term disability benefits, and health insurance denials, many of our clients are also tasked with keeping track of changes to their Social Security benefits. Here are some of the changes that will take effect on January 1, 2020 for Social Security recipients –

  • Social Security recipients will get a 1.6 percent cost-of-living adjustment (COLA) in their monthly benefits starting in January. The average individual retired Social Security beneficiary is expected to see a monthly benefit jump from $1,479 to $1,503, an increase of roughly $24 per month or $288 for the year.
  • As a result of the COLA, the maximum monthly benefit a single recipient can get also will grow. That benefit will increase from $2,861 per month in 2019 to $3,011 per month in 2020.

In his October 28, 2109 Opinion piece published by The Philadelphia Inquirer, Ross Waetzman opened with this harrowing sentence, “I almost died because of insurance prior authorization rules.” His story went on to share the details of how he nearly died as a result of the decision made by his insurer, Independence Blue Cross (“IBC” or “IBX”), to deny authorization of benefits for a test that had been recommended by Mr. Waetzman’s cardiologist.

The test Mr. Waetzman’s cardiologist had recommended was a cardiac catheterization. The test was necessary because Mr. Waetzman’s history of chest pain had been increasing in intensity, despite lifestyle changes he had made in an attempt to curb his symptoms. The cardiac catheterization was recommended by Mr. Waetzman’s cardiologist after less-invasive tests had been performed. Those less invasive tests, an EKG and a coronary calcium test, revealed that Mr. Waetzman was in the top 10% for his age and race for calcium deposits on his coronary arteries. With such deposits known to result in reduced blood flow to the heart, the cardiac catheterization was recommended to determine if Mr. Waetzman’s chest pain was a result of a blocked artery.

Unfortunately, when Mr. Waetzman’s cardiologist, Dr. Kenneth Mendel, called IBX, he was informed that “prior-authorization” for the cardiac catheterization was denied. IBX claimed that Mr. Waetzman did not meet all the necessary criteria to have the test and his only available option was to appeal the denial.

As we continue to learn about efforts to challenge proton therapy denials by groups such as the Proton Therapy Law Coalition, the fundamental question becomes: Will the insurers actually get the message and change their ways? A recent article suggests that even when a jury awards a large punitive damages figure against a health insurer, the carrier is likely not truly getting the message.

In November 2018, an Oklahoma jury returned a $25.5 million verdict against Aetna for improperly denying coverage for proton beam therapy, a treatment the company considered experimental. In the largest verdict for bad faith in U.S. history, the jury found that Aetna “recklessly disregarded its duty to deal fairly and act in good faith” and awarded punitive damages. During the course of deliberations, the jury specifically discussed “sending a message” to Aetna and “making a statement” so Aetna would reevaluate how it handles appeals and requests for coverage.

However, many large insurance companies, if state allows them to, carry their own liability insurance for just this occasion. It appears that about 20 states do not allow insurers to carry such liability coverage. But insurers are now turning to products sold by offshore insurers beyond the reach of state regulators. In other words, a lot of insurers are not directly paying for the punitive damages awarded against them. This undermines the importance and impact of large jury verdicts on effectuating changed insurer practices.

Breast-Cancer-Awareness
According to the Centers for Disease Control and Prevention (“CDC”), breast cancer is the second most common cancer among women in the United States.

  • In 2019, an estimated 268,600 new cases of invasive breast cancer will be diagnosed in women in the U.S. as well as 62,930 new cases of non-invasive (in situ) breast cancer.
  • Men also get breast cancer, but it is not very common. Less than 1% of breast cancers occur in men.

The Women’s Health and Cancer Rights Act of 1998 (WHCRA) was signed into law on October 21, 1998.   The WHCRA provides protections for individuals who elect breast reconstruction after a mastectomy. The WHCRA covers women who undergo a mastectomy for any medical reason, not just to treat breast cancer.

Under WHCRA, if your group health plan covers mastectomies, the plan must provide coverage for certain services relating to the mastectomy. However, if your coverage is provided by a “church plan” or “governmental plan”, you will need to check with your plan administrator as certain plans may not be subject to this law.

WHRCA rights apply to individual coverage as well and are generally within the jurisdiction of the state insurance department where you live.

Attend our October 2 Webinar About Insurance Coverage

You have had or are considering explant surgery.  We understand the physical and emotional pains that made you decide on the procedure.  We also understand that thinking about insurance coverage should be the farthest thing from your mind.

We have spoken with so many women about their troubles getting insurance coverage for these explants, that we thought it may help to put together some ideas, facts and resources that may resolve at least one part of these ordeals.

The correct response is, “maybe, or maybe not, depending on the facts, and the state in which you reside.”

Insurance policies very often have time limits on the submission of a claim for benefits. In some states, those deadlines are VERY strictly construed, and once the deadline has passed, it does become “too late” to make a claim.

However, more than half of the states apply some form of an insurance rule called the “notice prejudice” doctrine.  Simply put, even if an insurance policy imposes a time limit for the submission of the claim, if certain rules are met, a claim can be submitted after the time limit if the late notice does not “prejudice” the insurance company’s ability to investigate the claim.  However, that is just a basic summary of the rule.  In the states that apply some form of the notice prejudice doctrine, its application differs from state to state.  In some states, the insured making the late claim must demonstrate a “good reason” for making a late claim.  In others, the burden falls on the insured to prove that no prejudice would be suffered by the insurance company because of the late claim submission.

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