Frequently Asked Questions (FAQs)
Topic Categories:
Getting Approved
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Claims
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Administrative
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Miscellaneous
- A:Generally, 1 to 90 days from application date, assuming your application is approved. You can generally choose the effective date. If you have not had prior insurance within the last 63 days your effective date may be delayed by a month. Check with us.
- A:Most applications are approved within 2 to 3 weeks. A few applications are approved as soon as one day (but don't bank on it!), while a few applications can take a month or longer. The biggest delay in getting approved quickly occurs in those cases where the insurance company needs to get copies of your medical records, and the doctor's office is slow in sending them out. You can speed up the process by calling the doctor's office 5-7 days after you know your medical records were requested and ask the staff to expedite sending out the information to the insurance company.
- A:Medical history going back 10 years is what most carriers ask for. This includes the name of the condition, the approximate treatment dates, how it was treated, and whether you had full recovery or not. Be sure to have the exact name of medications and dosages that you have taken in the last 12 months.
- A:The price or "premium," as we call it, is approved by the Colorado Division of Insurance. Whether you buy from us, another agent, or even if you buy directly from the insurance company, the premium will be identical—so long as the quote is for identical features. At The Insurance Doctor, we work hard at listening to you, in order to understand what you want and need from your insurance plan. Then we offer you plan designs that best meet your needs, without trying to sell you a plan that is more expensive than necessary.
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The most popular payment method is a monthly bank-draft where the money is automatically taken out of your account each month to pay for your premium. A few companies are also allowing you to pay by credit card. You also have the option of sending in a check on a quarterly basis. Various other options may be allowed depending on the carrier.
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You have several good choices when applying for coverage depending on your personal preference:
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Online application. Has the advantage of usually giving you the fastest approval time. Disadvantage is it can be more confusing and complicated if you are not computer literate.
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Telephone application. Although not all companies offer this option, this is a very popular, fast and easy way to apply.
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Paper application. This is the traditional way of applying. It takes a little longer to process the application due to mail and data input time, but is an easy way to apply.
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There are, generally, four possible outcomes depending on the seriousness of your condition and what insurance company you are applying with:
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Standard issue. This means that the insurance company did not place any special exclusion riders on your policy and did not charge you extra on your premium. Standard issue is for people with no pre-existing conditions or for those with a minor, inexpensive condition, such as an under-active thyroid.
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Exclusion or rider. This means a pre-existing condition will not be covered—either permanently or for a certain period of time. For example, if you recently had knee surgery, your policy may exclude it for a year or two and cover if after that period—provided you have had complete recovery.
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Rate up. This means your premium is increased to compensate for the increased risk. Although you will pay more than standard, your pre-existing condition will be covered.
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Declination. This means the insurance company will not insure you under any circumstances. If you find yourself in this situation see the FAQ further down this page titled "What are my options if I am declined coverage?"
Our job at The Insurance Doctor is to help you find the carrier that will give you the best offer. We analyze all of the information you give us, then check our memory banks, our underwriting guides and, if needed, contact an underwriter at the insurance company to discuss your situation. After that we'll make a recommendation of which company will offer the best deal for you.
Even if you have been declined by another company, do not despair! While I am not a miracle worker, many times I am able to insure people who have been declined by a previous insurance company. Recently a lady came to me after being rejected by a company she had previously applied with. I was able to place her with another company—at standard rates and with no exclusions! How can this be? This happens because different companies have different internal guidelines they use for different health conditions. My job as a broker is to steer you in the right direction.
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A pre-existing condition is defined as any condition for which medical advice, diagnosis, care, or treatment was either recommended or received within 12 months of your health insurance application. Basically, this means anything you saw a health professional for in the past 12 months. It also includes any medications you took in the past 12 months.
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This is a very complex and confusing area! The 12-month notice applies to an individual plan. Your reference to a 6-month notice for pre-existing conditions (after which pre-existing conditions are covered), would apply only to an employer-based group plan, so you probably saw that on some other notice from an employer's group plan.
Now here is where it gets really confusing. The insurance company does have the right to look at your answers to their medical questions and carve out any pre-existing conditions that concern them. They can place a special "elimination rider" or "exclusion rider" at the time they issue your policy. This means that particular pre-existing condition will not be covered—either permanently or for a certain period of time. However, if an insurance company doesn't put a special exclusion rider on your policy when they are looking at your particular application, then its true—they are stuck with paying for a pre-existing condition after the 12 month period. Still confused? That's ok, most people—even insurance agents—get confused on this one. Just call us if you need further clarification.
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No! While not an uncommon idea, this would be a horrible mistake! Besides the fact that you would be lying to the insurance company, let me tell you how doing something like that can come back and bite you. Let's say that you have a relatively minor health issue from a medical standpoint, but one that from an insurance standpoint would cause you to be declined by the particular insurance company you applied to. You don't say anything to the insurance company and get approved. Now let's suppose that a year and a half later, you have a heart attack. When a big claim hits, the first thing the insurance company will do is send off for all of your medical records from every doctor you saw in the last 10 years to make sure that you did not hide anything related to a pre-existing condition with your heart. They find nothing in relation to your heart, but they do discover that you failed to disclose that other condition for which you don't even plan on filing a claim. Now, here's what's going to happen. The claim department will transfer the file to the underwriting/new business department and ask them to answer the following question: "If you had known about this condition at the time of the application, would you have issued the policy? If the answer is "yes," you're okay—they will pay for your heart attack. But, if the answer is "no", you'll be in for the shock of your life. The insurance company will send you a letter "rescinding" your policy. What this means in legal terms is that because you lied on the application, the policy is terminated. The company will refund all of the premiums you had paid since the first day of the policy and you will be without insurance in the middle of your heart attack.
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The most obvious way is they ask you during the application process. A second way is the use of a data-base called the Medical Information Bureau (MIB). The MIB will alert the insurance company if you have previously been denied coverage or been rated-up. The MIB will also have information about hospital admissions. Third, the insurance company uses a database to learn about medications you have ordered from your pharmacy. If the carrier still does not have enough information, they will write directly to your doctor and obtain a copy of your medical records—this occurs with about 10 to 30% of applications, depending on the carrier.
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Do not despair or give up. You do have options! Give us a call to talk things over. The first step is to find out exactly why you were declined. If the company does not send you a detailed reason, you can request a written explanation which usually will be sent to you; other times it will go to your doctor if it contains sensitive medical information. In that case you'll need to call the doctor and have him give you a copy of the letter from the insurance company. Once you know the reason for the carrier's decision, you'll want to sit down with an experienced broker to analyze the situation and decide whether to appeal. I have had good success in overturning adverse decisions when the carrier based its decision on incorrect or partial information, as well as in certain "borderline" situations where the decision could go either way. These cases are not easy and they are a lot of work—but that it the value of a good broker...you have an advocate guiding you and fighting for your interests! Other times, the decision of the carrier appears correct, in which case I will tell it to you straight—that the decision is correct per the company's guidelines, after which we will discuss your options. While this may not be what you want to hear, hopefully, you will appreciate someone who tells you the truth, explains your options, and tries to find you the best possible deal.
A second possibility is to go to another company since each company uses its own criteria in deciding who gets approved or rejected. Again, we can tell you if this approach looks promising or not. The next step is to see if you can get on a group plan, either though your employer or through a spouse. If that fails also, your final option is to get on Cover Colorado, which is a plan of last resort run by the state of Colorado for people who cannot get coverage elsewhere. While Cover Colorado is more expensive, it is better than nothing. Cover Colorado's number is 866-787-9129.
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The surest way is to call your doctor's office and check. Since some carriers rent a network be sure to give the doctor the name of the network not just the insurance company. You can also go online to check. Just go to our doctor network page and click on the link. Finally, you can call a toll free number shown on your ID card.
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Group: True group insurance can only be obtained through your employer. The one exception is for a state mandated plan called a "Business Group of One" or "BGO" for short. BGO's are true group insurance because they guarantee your acceptance, regardless of health. Watch out for agents marketing fake "group" insurance which does not guarantee your acceptance and coverage for pre-existing conditions! If you are approached by such an agent—run for your life...it is a huge tip-off that something is fishy. Group insurance is always guaranteed issue—you cannot be turned down, regardless of your health. Most of the time group insurance is dramatically more expensive than individual coverage, although many people think the opposite is true. The reason that group insurance seems cheaper is because your employer is picking up the lion's share of the cost! Some of the reasons group insurance is more expensive are: it is guaranteed issue so claims are higher; it covers several expensive state mandated benefits—the biggest being maternity and mental health.
Individual: To obtain individual health insurance you have to answer numerous questions and you may or may not get approved. However, if you are approved the premiums will be dramatically less than group insurance. Another advantage of an individual plan is you don't lose it if you quit work or change jobs. A disadvantage of individual insurance is that most plans do not cover maternity and mental coverage is poor. Click here if you are in need of maternity coverage. Maternity Plans
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A "Self Employed Business Group of One," or "BGO" for short, is a true group plan mandated by the state of Colorado. If you meet the requirements for a BGO you, and any family members who are applying, will be approved regardless of your health status. Anyone with qualifying prior health insurance for the last 12 months will have their pre-existing conditions covered immediately. Otherwise, preexisting conditions will not be covered for the first 12 months.
Here are the rules to qualify for a BGO plan:
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You must have had a business for at least 12 months.
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You must provide copies of your tax returns to prove that you have a bone-fide business.
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You must work at least 24 hours a week in the business.
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You must have "substantial" income from your business.
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Your application must be received by the insurance company during an open enrollment period. In most cases, the open enrollment period will be the 30 day period starting with your birthday. It is crucial that you apply in plenty of time to make sure that your application reaches the home office in time as there are absolutely no exceptions for late applications. If you have been operating your business for less than one year, then you will also have a special open enrollment period which will first occur upon your first 12th month anniversary.
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No. The rates are controlled by the Colorado division of Insurance, so your premiums will be identical regardless of whether you buy from us or go directly to the insurance company. By going through us you'll get better service because you'll be getting our help and advice if you have a problem with the insurance company. Also, if the company we place you with gets too expensive down the road, as an independent broker we can simply move you to another company.
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Yes, but as Paul Harvey likes to say, "Here is the rest of the story." The premium on a policy without drug coverage is considerably less than one with drug coverage. Obviously, this reflects the high cost of drugs. It is tempting to say, "Well, I don't use drugs a lot, so I think I'll go without drug coverage in order to save money." Before you make your final decision, just keep in mind how expensive dugs are. Don't think that $100 or $150 a month is an expensive drug these days. $300 a month is only moderately expensive now. For example, Colorado has one of the highest if not the highest, incidence of multiple sclerosis (MS) in the country. The most common drug to treat MS runs between $1500 to $2000 per month—up to $5000 per month for those needing multiple drugs. Big ouch! But wait. There's more! There is a new wave of bio-engineered biological drugs which are made in small batches for niche medical conditions. Some can even be tailored for your own body! The cost of these drugs? Hold on to your chair—they average $74,000 per year! Granted the odds of your needing such drugs are low, but if you need one of these super expensive drugs wouldn't you like to have access to them in order to lead a more normal, active, pain free life? Only you can make a decision on what level of risk you are willing to take. Just know the facts before you buy your policy. Now you can begin to understand not only why insurance is so expensive in general, but why a policy without Rx coverage costs so much less.
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Yes, you will have a 10 "free look" period starting with the day you receive your policy. So long as the company receives your returned policy before the 10 days expires, you will get a full refund, no matter what your reasons. (Some carriers charge an "application fee" of anywhere from $20 to $40 dollars. That is the only part of the premium that will not be refunded.)
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One advantage is that network doctors or other healthcare providers, handle all the
paperwork for you so that you have no claims to file. But the main advantage is that since
insurance companies have negotiated a schedule of lower charges, the medical services
from network providers is less expensive. (This also explains why insurance companies
charge less in premiums for PPO and HMO plans.)
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Medically necessary claims will most likely be covered. However, you will generally
be subjected to severe out of network penalties so it is best to make sure you are going to
a network provider. Last of all, you will be responsible for filing your own claims.
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Most (but not all) of our carriers have a nationwide network, so you should be able to find a
doctor and hospital out of state. However, if you see a non-network provider you will
generally be paid at the out of network rate.
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Call us! Our service to you does not end when you buy a policy from us! We will
review with you the reason for the claim denial. If it appears a mistake was made we will
show you how to file an appeal. An example of a common reason for a claim denial
occurs when the doctor's office sends in the wrong procedure code for you. This is easily
fixed by having the doctor send in a corrected billing form.
One of the things that saddens and frustrates me the most is to hear from a client a year
or two after a claim problem occurs and to learn that they are upset with the company. If
only they had called me earlier I could have helped them, gotten their claim paid and
everyone would have been happy. On the other hand, if the denial was legitimate, I could
have told them so they would not wonder if they were cheated or not.
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Many times an exclusion rider will state that it is for a certain duration, say one, two, or
three years. This means that after the stated period of time you can make a written request
to the carrier and ask for a removal of the exclusion rider. You will have to certify that you
have not had any more problems with the condition and have not had any treatment, such
as taking medications. You may also be required to provide a note from your doctor
verifying your statement. Assuming that you have had full recovery, in most cases, the
exclusion will be removed!
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All policies are required to cover "complications of pregnancy." Your policy will
define a complication. A cesarean section (C-section), for example, is generally considered a
complication of pregnancy, if it is "medically necessary" and not simply for your
convenience or the convenience of the doctor.
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Although this is a key area of health insurance coverage, there are huge differences
among insurance plans on how prescription drugs are covered.
Here is a list of the most common possibilities:
- Both generic and brand name drugs are covered with a copay, meaning that you
bypass the deductible for prescription drugs.
- Only generic drugs are covered with a copay. There is no coverage for the more
expensive brand name drugs.
- Prescription drugs are not covered at all—unless you are actually in the hospital.
- Prescription drugs count as any other medical expense and go toward the
deductible.
- A discount Rx card with savings of "up to" 60% on drugs. While you may get such
a discount on a few drugs, the reality is your average savings are going to be closer to
about 15 to 20%.
- Drugs covered with a copay after you have met a separate drug
deductible.
The premium on a policy without drug coverage is dramatically less than one with drug
coverage. Obviously, this reflects the high cost of drugs. It is tempting to say, "Well, I
don't use drugs a lot, so I think I'll go without drug coverage in order to save money."
Before making your final decision, just keep in mind how expensive drugs are. Don't
think that $100 or $150 a month is an expensive drug these days. $300 a month is only
moderately expensive now. For example, Colorado has one of the highest, if not the
highest, incidence of multiple sclerosis (MS) in the country. The most common drug to treat MS
averages around $2000 per month—up to $5000 per month for those needing multiple drugs. Big ouch! But wait. There's more! There is a now
wave of bio-engineered biological drugs which are made in small batches for niche
medical conditions. Some can even be tailored for your own body! The cost of these
drugs? Hold on to your chair—they average, $74,000 per year! Granted the odds of your
needing such drugs are low. But if you need one of these super expensive drugs wouldn't
you like to have access to them in order to lead a more normal, active, pain-free life?
Only you can make a decision on what level of risk you are willing to take. Just know the
facts before you buy your policy. Now you can begin to understand not only why
insurance is so expensive in general, but why a policy without Rx coverage costs so much
less.
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Most expenses that are covered by the policy count toward your deductible. Excluded
expenses do not count toward your deductible. Thus, if you have an exclusion rider for
allergies, those expenses would not accumulate toward your deductible. Copays also do not count towards your deductible.
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Well, not quite. No policy in the world covers "all" medical expenses. Every policy
has a list of exclusions, which you should read before purchasing the policy, so there are
no surprises later. A policy that is issued "standard" simply means there are no special
exclusions that pertain just to you.
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If you are in an indemnity plan you can see any doctor you want. However, if you are in a PPO or HMO, as most people are, you will want to see a network doctor. While you are allowed to go outside the network in a PPO plan, your deductible will generally double and the insurance company will reimburse you at a lower percentage.
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Yes, you will have a 10 "free look" period starting with the day you receive your policy. So long as the company receives your returned policy before the 10 days expires, you will get a full refund, no matter what your reasons. (Some carriers charge an "application fee" of anywhere from $20 to $40 dollars. That is the only part of the premium that will not be refunded.)
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No, your coverage cannot be cancelled if you get sick or have high claims. Also, the insurance company cannot charge you more because you have high claims. Unlike auto insurance, your premiums are based on claims by all policyholders in Colorado, not on your own claims.
You can only be cancelled for the following reasons: failure to pay premiums; committing fraud or misrepresentation; moving out of the service area; or if the insurance carrier cancels all policyholders in Colorado with the same plan as yours.
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If you are in an indemnity plan you can see any doctor you want. However, if you are in a PPO or HMO, as most people are, you will want to see a network doctor. While you are allowed to go outside the network in a PPO plan, your deductible will generally double and the insurance company will reimburse you at a lower percentage.
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No. The rates are controlled by the Colorado division of Insurance, so your premiums will be identical
regardless of whether you buy from us or go directly to the insurance company. (This assumes you are
getting an exact apples-to-apples quote. Any small change—age, smoker status, zip code, benefit options,
etc. will yield different rates.) By going with us you'll get better service—our help and advice if you have
a problem with the insurance company. When necessary, I have actually helped clients compose letters of complaint to
the Division of Insurance and fought for justice alongside my client. I have also gone into formal hearings
to testify on behalf of my clients when the company unfairly refused a claim. Also, if the company we place
you with gets too expensive down the road, we'll move you to another company! Bottom line, you'll get better
service at no extra cost by buying from an experienced, independent broker!
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Whether your case is simple, or full of complications, there will never, ever
be a charge to you! The way we get compensated is a commission directly from
the insurance company for providing them with a new client. Please note that this commission DOES NOT INCREASE THE PREMIUM IN ANY WAY. Since we are brokers, we don't push just
one company—we offer you a variety of companies and plans to choose from. We give you a much more
objective and thorough analysis of the pros and cons of a policy than if you try to buy directly
from the insurance company or from an agent that only represents one company.
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Go to our Insurance 101 page.
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This will vary with each insurance company. Most companies guarantee their rates for 12 months. Some only for 6 months. A few are experimenting with 24 to 36 month rate guarantees!
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There are three main factors that determine the amount of your rate increase:
First, the insurance company looks back and determines the total amount it paid out in claims
from all their policies in the state during the past year.
Second they look, forward and based on statistics for the entire industry, estimate how fast medical expenses
are expected to increase in the next 12 months, based on doctor and hospital charges, drug cost increases and other factors. This is called
a medical "trend factor."
Third, since you will be a year older, the premium is adjusted for your new age.
Then they add up the numbers to figure the rate increase—one that is usually makes us want to scream with anger! It is important to note that the insurance companies do not
look at your personal claims in setting rates but rather at the entire block of business in your geographic region.
While I, too, get upset by big increases (after all, I pay exactly the same premiums for my health insurance
as anyone else), do keep in mind that the increases are due to real expenses that the company must pay out.
Companies do not set arbitrarily high rates because they want to make an obscene profit as many people seem
to think. It is a highly competitive business and, believe it or not, companies are frantically trying to
keep rates down so they can attract more business—not drive it away! All rate increases must be approved
by the Colorado Division of Insurance, which is a consumer watchdog.
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"HSA" stands for Health Savings Account. It consists of two parts:
- a low-cost insurance policy with a high deductible, and
- a side-fund savings account.
An HSA is like an IRA on steroids, where the side-fund money is used to pay for your medical expenses. It is designed for the person who is willing to self insure for minor healthcare expenses by building a reserve fund to take care of expenses up to your deductible. Click here for a full explanation of how HSA's work.
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First, we make sure that the personal information you send to us is not intercepted and stolen while it is being transmitted to us. Sending personal sensitive information via email is a no-no since it is NOT secure and can be hacked into during transmission. Incredible as it sounds, however, the majority of insurance web sites that give you quotes collect all sorts of personal information on you but fail to use encryption technology! Instead they use simple email because it is easier and cheaper.
Click here to see our full privacy policy.
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The surest way is to call your doctor's office and check. Since some carriers rent a network be sure to give the doctor the name of the network not just the insurance company. You can also go online to check. Just go to our doctor network page and click on the link. Finally, you can call a toll free number shown on your ID card.
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Sometimes this can be a difficult task. Here are several suggestions.
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Check with friends and relatives for good and bad experiences with various companies.
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Check on the financial strength of the company. The best source for unbiased financial information is the "A.M. Best" rating, which is considered to be the "Bible" of the insurance industry. Any company with a rating of "A-" or higher is good for the health insurance industry. Please note, however, that the rating has nothing to do with how good the coverage is or how good the service is. It only tells you if the company is on a solid financial footing.
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Check the complaint ratios for the company.
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See an experienced and trusted insurance broker. While the above steps will give you some help, they have their limitations. Friends only give you a glimpse of one or two experiences. Complaint ratios are somewhat helpful but one must know how to interpret them properly. An independent insurance broker, such as The Insurance Doctor, has the advantage of dealing with many insurance carriers over many years. We use our own personal experience, along with the feedback we get from our clients, as well as statistical research when we decide on which company to recommend.
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COBRA is a Federal law that allows you to stay on your group plan for 18 months after you leave employment. (Under some limited circumstances you can stay longer than 18 months.) The premiums are whatever your former employer is being charged by the insurance company. Since your employer will no longer be subsidizing the cost of the insurance, the premiums may be quite high. Each family member on COBRA has an independent right to stay on COBRA, regardless of whether the former employee takes COBRA or not.
Here's a money saving tip: Have the healthy employee take an individual policy, while those with pre-existing conditions stay on COBRA.
