Questions and Answers July 2004

Q. I have an individual Horizon Plan C health insurance plan with a $1500 deductible. Horizon is not paying any of the claims. Why?

A When I asked him how long ago he had submitted the claims (everything was out of network), he replied that he hadn’t submitted anything! If the service is done out of network, it is your responsibility to submit the claim. No one else will do it for you, and if you don’t submit the claims, the insurance can’t possibly pay them.

Q. I recently left my job on a Friday and was told by my former employer that I had to deliver a check to her house by Sunday if I wanted to continue my health insurance benefits under the NJ Continuation Law. Is this true?

A: No, it is not true. Your employer must notify you in writing of your right to continue your benefits and you have 30 days to pay the first premium. Subsequent premiums must be paid in a timely fashion no later than the date they are due, as stated in your notification letter. (This question and answer is relative to NJ small group health insurance plan.)

Q. My father is 97 and has a Medicare HMO and wants to get back to the traditional Medicare program. How can he do this?

A. Call the HMO and tell them you want to disenroll. They will send you a form to complete. When they receive the completed, signed form, they will take the necessary steps to disenroll your father. They will also notify Medicare of the date your father goes back on traditional Medicare. Now he will need a Medicare supplement to pick up where Medicare leaves off. Be sure to do your homework concerning a Medicare Supplement first. Depending on your Dad’s medical situation, he may not have complete freedom of choice in choosing a Medicare supplement.

Q. I submitted a claim to my secondary insurer but they rejected it saying they want a copy of the explanation of benefits from Medicare. How do I get a copy of it?

A. Call 1-800-MEDICARE. The explanation of benefits is actually called a Medicare Summary Notice. When you call, have the date of service and name of provider handy.

Q. I have Medicare and a Medicare supplement. Do I need a referral to see a specialist?

A. No, with Medicare and a Medicare supplement, you have complete freedom of choice. You can go to any provider in the United States; no permission needed. Just make sure they are Medicare providers.

Irene Card & Betsy Chandler share the responsibilities of running Medical Insurance Claims, Inc. a health insurance services company. If you have questions relative to this column or other related topics, we invite you to call (973) 492-2828, browse our past columns on our web site at www.micinsurance.com.

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