Health insurance overview
- Insurers pay for the medical services outlined in your insurance policy.
- They do not pay for medical treatments listed in the policy exclusions.
- Insurers only pay for medical treatments that are medically necessary. Medically necessary is defined in your insurance policy.
- Insurers do not pay for medical treatments that are experimental or investigational.
- If you are age 19 and older, insurers may deny payment for treatment of pre-existing medical conditions for up to six months or 12 months if you are a late enrollee in a group plan or work for a business that self-insures (pays claims itself rather than buying insurance).
- If you had health insurance within 63 days of the start of the new policy, you get credit for this coverage and the waiting period is reduced one month for every month of coverage you had. This may reduce or even eliminate the waiting period for coverage of existing medical conditions.
- If you are under age 19, insurers may no longer make you wait for coverage of pre-existing conditions.
- Insurers may require that you get prior approval for medical treatment from the insurance company before the insurance company will pay for the treatment.
- You are not required to get preauthorization for emergency medical treatment. Insurance companies must give you a written explanation about emergency medical treatment.
- Unless your plan is "grandfathered" under federal reform law, it must cover certain preventive services such as mammograms and colonoscopies without charging a deductible, co-pay, or co-insurance. This takes effect for new plans purchased on or after September 23, 2010 or when an existing non-grandfathered plan first renews on or after Sept. 23, 2010.
- Oregon requires insurance payment for specific medical treatments (mandates) for some insurance plans. Some of these mandates also qualify as preventive services under federal law and are therefore not subject to cost sharing (deductibles, co-pays, co-insurance, etc.). For those that do not qualify as preventive services, however, insurers may impose cost sharing. To see the list visit: www.cbs.state.or.us/external/ins/sehi/mandated_health_provisions.pdf
Final coverage decisions are usually based on detailed medical records. Discussions with an agent or company representative do not change how a policy covers a procedure. Insurance companies have detailed, procedure-by-procedure guidelines on when coverage is allowed. You can ask for these guidelines.