Overview Of Health Care Issues
by
Herbert D. Hinkle, Esq. and Valerie A. Powers Smith, Esq.
Hinkle & Fingles, Attorneys at Law
2651 Main Street
Lawrenceville, New Jersey 08648
(609) 896-4200 or (215) 860-2100
This article is designed to provide a brief overview of the
different forms of insurance and common issues which, in our
experience, have given rise to an appeal. More detailed discussions of
the individual topics contained in this article and more can be found
in subsequent companion articles by the authors.
There are various areas that may give rise to an appeal regarding your
health care coverage. Most commonly, disputes involve denial of
payment for a covered benefit, which is medically necessary;
reduction, denial, or termination of a covered service (with or
without notice); and denial or termination of eligibility for
insurance or waivers are all issues that may give rise to an appeal.
If you are covered by more than one form of insurance (e.g., private
insurance and Medicaid or Medicare, or Medicaid and Medicare),
coordination of benefits and billing dispute issues can also arise. If
covered under Medicaid or Medicare, due process issues (notice and
opportunity for a hearing), failure to continue services pending an
appeal, and failure to restore services pending a timely appeal can
also give rise to an appeal.
In order to correctly appeal any of the above-stated issues, you must
first understand the type(s) of insurance plans under which you or
your family are covered, as this will dictate eligibility, coverage,
and appeal rights.
One may receive insurance coverage for health care services under: (1)
private insurance; (2) public assistance (Medicaid or Medicare); (3)
state-funded health benefits plans; and (4) self-funded/-insured
plans.
PRIVATE INSURANCE is either employer-provided or purchased on your
own. These types of plans are governed by NJ law and are enforced,
depending on the issue, by the NJ Departments of Health & Senior
Services’ Office of Managed Care (DOHSS/OMC) and Banking & Insurance (DOBI).
Beneficiaries of private, managed care plans are afforded three levels
of appeal - - two internal appeals within the insurance plan and a
third external review before an Independent Utilization Review
Organization (IURO) under contract with the DOHSS/OMC. The IURO
decision is binding on all parties. DOBI reviews billing disputes and
mental health parity issues.
PUBLIC ASSISTANCE coverage includes Medicaid (fee-for-service, EPSDT
Program, managed care, or Waiver Programs) and Medicare coverage. The
various forms of Medicaid coverage and Medicare require more
discussion than this article allows. In short, Medicaid is a
federal-state entitlement program for low-income Americans. Medicare
is a partner program to Social Security, which provides a health and
financial safety net to those 65 years and older and to those declared
disabled for 24 months. There are individual eligibility requirements
for these public assistance programs and they all provide different
(or additional) appeal rights than the other forms of insurance
discussed herein.
STATE HEALTH BENEFITS PLANS (SHBP) are provided to individuals who are
employees of the state. This coverage is similar to private
employer-provided plans in that it is a fringe benefit of employment;
but is dissimilar in the nature of the plan. SHBP are
self-administered medical plans, which are not under NJ’s Departments
of Health & Senior Services and Banking & Insurance or the U.S.
Department of Labor. Therefore, SHBP have greater leniency in what
they cover (or not) and in what duration because they are similarly
not subject to NJ’s insurance laws. Like private, managed care
insurance, SHBP beneficiaries have two internal appeal levels; but the
third external appeal level is before the State Health Benefits
Commission (SHBC). The decision of the SHBC is final, yet appealable
to the Office of Administrative Law (OAL).
SELF-FUNDED/-INSURED PLANS are offered by a private employer that has
decided to assume the risk of insuring its employees. Under most
employer-provided plans, the employer pays premiums to an insurance
company, who assumes the risk of insuring the employer’s employees and
administers the plan (and handles all of the claims). Where the
employer assumes the risk, an insurance company is hired to administer
the plan and handle all of the claims. As with the SHBP, self-funded
plans have greater latitude as to what they do and do not cover under
the plan. Any appeals under such a plan must be filed with the U.S.
Department of Labor. It is, therefore, important to examine the cover
of your member handbook to determine whether you have this type of
plan.
Understanding your insurance coverage will assist you to maximize your
health care benefits and understand your responsibilities and rights
under the plan.
______
Herbert D.
Hinkle, his partner, Ira M. Fingles, and their colleagues, S. Paul
Prior and Valerie A. Powers Smith, maintain a statewide
law practice with offices in Lawrenceville, Marlton, and Florham Park,
New Jersey, and Yardley, Pennsylvania. They lecture and write frequently
on topics of law, aging, disability and estate planning and are available
to speak to groups in New Jersey and Pennsylvania
at no charge.
Comments and suggestions
for future articles should be mailed to: Hinkle & Fingles, 2651 Main Street, Suite A, Lawrenceville, New Jersey 08648-1012.
Copyright 2005
Herbert D. Hinkle. All rights reserved.
