Limitations of Coverage
provided by Texas Department of Insurance
(link
here)
please see page for updates
Utilization review
Carriers may deny payment for any treatment, or the continuation of any treatment, if they deem that it is not “medically necessary.” Many health plans perform “utilization review” before non-emergency medical procedures are approved. The review must be conducted by an appropriate physician, dentist, or other health care provider, and any decision denying treatment must include a medical reason. State law requires the criteria used to approve or deny requested services or treatments to be objective, medically (clinically) valid, compatible with established health care principles, and flexible enough to allow deviation from standard guidelines when justified on a case-by-case basis.
If you have an unresolved complaint about a utilization review for an individual, small-employer, or large-employer plan, you may file a complaint with TDI. If you have a complaint about a self-funded plan, contact the U.S. Department of Labor.
To reduce the chance of a claims problem, read your policy or benefits booklet carefully. Be sure you meet all of the plan’s requirements, and keep copies of all correspondence with your carrier and health care provider.
Approval of treatment is not the same as approval for payment. You may still need to file a claim after the procedure. Carriers can refuse payment for portions of approved treatment if they are found to be “unnecessary expenses.”
Pre-existing conditions and waiting periods
If you currently have a medical problem, or have had one in the recent past, it may meet a plan’s definition of a “pre-existing condition.” Most plans will require you to wait a period of months, or sometimes years, before paying benefits for treatment related to this condition.
You must disclose any pre-existing conditions in your application for any health plan. Failure to do so could jeopardize future claims or invalidate the policy.
Carriers may define a pre-existing condition as any condition for which you’ve received medical advice, care, diagnosis, or treatment during a specified period of time before the plan takes effect. In addition, individual plans can define a pre-existing condition as one where you’ve shown the existence of symptoms likely to cause you to seek diagnosis or care during the period before the plan begins. Typically, individual plans consider your medical history for the previous five years to determine whether you have a pre-existing condition. Employer-sponsored plans typically consider the previous six months, while other group plans usually look at the previous 12 months.
An individual carrier may decline to cover you entirely on the grounds of a pre-existing condition, or the carrier may insist on a special policy “rider” that excludes treatment for the condition. Group carriers may not insist on a pre-existing condition exclusion rider.
The maximum pre-existing waiting period for an individual health plan is two years. The maximum wait for employer-sponsored health plans is one year. You may have to wait up to two years for pre-existing conditions to be covered if you have coverage through a group plan that’s not sponsored by an employer.
Some plans may require a standard waiting period before new members are eligible to receive any benefits, regardless of whether they have a pre-existing condition or not. If this is the case, your pre-existing condition wait begins with the start of the waiting period. For example, if your plan has a waiting period of three months and a pre-existing condition waiting period of one year, a new member would be eligible to receive benefits for a pre-existing condition nine months after the waiting period ends.
HMOs have an “affiliation period” that works in much the same way as a waiting period for pre-existing conditions in indemnity plans. However, the affiliation period may not be longer than 90 days.
Reducing or eliminating pre-existing condition waits
If you’re switching from one health plan to another, or have recently had health coverage, you may have a shorter waiting period before your pre-existing conditions are covered.
The amount of time you spent covered under the previous health plan is “creditable” toward any new plan’s waiting period, as long as there is no gap in coverage greater than 63 days. For example, if you’ve been covered by a health plan for the past six months, and then switch to a new plan with a pre-existing condition waiting period of one year, you get “credit” for your previous coverage and you only have to wait six months. If you had coverage under the previous plan for a year, you wouldn’t have a waiting period with the new plan.
The following table summarizes how health plans handle pre-existing conditions:
| Pre-Existing Condition Summary |
| |
Group Plans |
Individual Plans |
| Pre-existing condition definition |
You received diagnosis, care, or treatment within six months prior to joining an employer-sponsored plan, or one year prior to joining a non-employer group plan |
You had symptoms likely to cause you to seek medical advice, diagnosis, care, or treatment, or a condition for which you received medical advice, diagnosis, care, or treatment, within five years prior to joining |
| Waiting period before a pre-existing condition is covered |
12 months for plans offered by employers; up to 24 months for non-employer plans (from churches, unions, associations, etc). |
Up to 24 months |
| If you’re moving from a group plan to a … |
Your waiting period is reduced on a month-for-month basis. If previous coverage lasted 12 months, there is no wait for an employer group plan |
Carrier may refuse to accept you because of a pre-existing condition or may include a rider eliminating coverage for the condition; coverage is credited on a month-for-month basis |
| If you’re moving from an Individual plan to a… |
Your waiting period is reduced on a month-for-month basis; if previous coverage lasted 12 months, there is no wait |
There is no law requiring credit for a waiting period; the new carrier may refuse to accept you, include a rider eliminating the condition from coverage, and require a full 24-month waiting period |
Long-term care
“Long-term care” refers to the type of personal care services you may need if you become unable to care for yourself because of a loss of functional capacity or cognitive impairment.
Long-term care is different from traditional medical care. Traditional medical care treats physical problems directly in an attempt to permanently cure or control them. Long-term care services, however, help a person maintain his or her ability to function, perform normal daily activities, or maintain a normal lifestyle.
In general, health plans do not cover long-term care. Some may cover short-term nursing home care, but long-term custodial care in a nursing home or at-home custodial care typically requires a special long-term care policy.
