Health Insurance

If You’re Blindsided By Health Plan Changes, Learn The Root Causes — And Your Rights

If You’re Blindsided By Health Plan Changes, Learn The Root Causes — And Your Rights

How much notice is required if benefits change? Do insurers have to give you a heads up if your plan doesn’t meet the minimum coverage standard under the Affordable Care Act?  Readers’ questions this month are centered around insurance notification requirements.

Q: My father’s health insurance coverage through his company was reduced without him being aware of the change. The insurance company continued to cover my parents’ bills until 10 months after the change. Now it’s trying to charge my parents for all of my mother’s doctor visits to manage her multiple sclerosis during that time. This will result in thousands of dollars in repayments. Can the insurer do that?

You may need to do some digging to figure out what’s going on here. Health plans can reduce the benefits that they offer or increase cost sharing during the plan year, but under the Affordable Care Act they generally have to notify enrollees 60 days before any changes become effective.

That doesn’t always happen, said Dania Palanker, an assistant research professor at Georgetown University’s Center on Health Insurance Reforms.

“It is very possible that something was done incorrectly, particularly if you have a self-funded employer that’s doing all the claims processing in-house,” said Palanker, who is a former health plan administrator.

Since the health plan continued to pay the claims for your mother’s multiple sclerosis for 10 months after the change, this may not be a notification problem, however.

“It suggests that the insurance company did a claims audit and determined that they should never have been paying these claims,” Palanker said. Such audits are common. “They do it routinely to try to identify fraud and abuse.”

Some states don’t allow insurers to retroactively adjust claims except in cases of fraud.

Your first step should be to contact the health plan to find out why the claims were denied retroactively. Then, regardless of the reason for the back charges, your parents “should absolutely complain, no matter what,” said Karen Pollitz, a senior fellow at the Kaiser Family Foundation. (Kaiser Health News is an editorially independent program of the foundation.)

Depending on what you learn, your dad’s human resources department may be helpful in resolving the problem, said Pollitz. Or you may need to file an appeal with the health plan, complain to your state insurance regulator or to the federal Department of Labor.

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