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 Types of Health Care and Insurance

Medical Benefits and Subsidies

The Center for Medicare & Medicaid Services (CMS) administers programs that help provide medical insurance to seniors, individuals with disabilities, and low-income persons. In particular, CMS administers the following programs:

  • Medicare is a health insurance program for people 65 and older and certain disabled individuals. There are two aspects of Medicare: hospital insurance, which most people do not pay for, and medical insurance, which many people pay for monthly.
  • Both states and the federal government administer Medicaid. Qualifying seniors will receive most of their nursing home costs through Medicaid. Medicaid is limited to low-income individuals with limited resources.

You may need to consult with Medicare and Medicaid Lawyers to obtain the coverage and benefits you are entitled to.

Is Health Insurance Mandatory?

As of January 1, 2019, health insurance coverage at the federal level is not mandatory. Some states still require individuals to have health insurance to avoid paying a tax penalty. The absence of health insurance may save an individual money because they are not paying a premium, but it may also put them at risk if they become injured or ill.

Are There Laws to Protect Consumers from Health Insurance Discrimination?

Yes, various rules and regulations protect consumers from discrimination in health insurance. One of these is the Affordable Care Act, also known as the ACA or Obamacare.

Per the ACA, it is illegal for an insurance company to deny an individual coverage based on a pre-existing condition. A pre-existing condition, or pre-existing illness, is an illness an individual has before they apply for their health insurance plan.

A pre-existing condition may include a chronic or long-term condition. In certain cases, pregnancy may be considered a pre-existing condition for the purposes of a health insurance policy.

According to federal laws, an insurance company cannot deny an individual coverage because of their:

  • Race;
  • Color;
  • National origin;
  • Sex;
  • Age; or
  • Disability.

Other insurance rules, regulations, and laws may also apply. These include the Health Insurance Portability and Accountability Act (HIPAA) and the Employee Retirement Security Act (ERISA). As a result of these laws, insured and retired employees are provided with additional protections.

What Should I Do If I Can’t Afford Health Insurance?

Individuals without health insurance have several options. Subsidized health insurance is one option. Individuals making under a certain income level are likely to qualify for a subsidy on the health care exchange.

People who cannot afford insurance may opt for a catastrophic health plan or a short-term health plan. These plans are cheaper. It is important to note that they do not typically cover things like regular doctor visits, but they will protect an individual if they have an accident or substantial diagnosis.

What Can I Do if I Have a Health Care Plan Dispute?

A person with a dispute regarding their health care plan should contact their insurance company. An individual should follow a few basic steps.

A person should first check their insurance agreement, including their Summary of Plan Description and Evidence of Insurance Coverage. To ensure that the policy covers a disputed claim, it is important to check the policy. You can contact customer service to request reversal of the improper charge or denial of coverage.

An individual’s insurance carrier should send the individual a denial of coverage or cancellation letter. A reason for the denial or cancellation should be included in the letter. Insurance companies are required by law to provide notice before canceling coverage.

If customer service cannot reverse the improper charge or coverage denial, the individual should write to the carrier disputing the denial or cancellation. The individual’s insurance carriers will conduct an internal investigation to determine whether or not they erroneously denied coverage or canceled the policy.

Since no outside agency is used to resolve the complaint, it is called an internal review.

When Do Health Insurance Disputes Arise?

There are several ways in which health insurance disputes may arise. Common health care disputes include, but are not limited to:

  • Denial of medical benefits or services;
  • Refusal to authorize an insured individual’s hospital visit or medical procedure;
  • Charges for medical services that are incorrect;
  • Cancellation of health insurance policies without notice;
  • Refusal to carry over a policy when an individual changes jobs.

Multiple parties may be involved in a health care dispute, such as:

  • A person who is insured;
  • Provider of the insurance policy;
  • An employer;
  • A medical company;
  • Others who might be interested.

Usually, however, a health plan dispute involves a direct claim between the insured individual and the insurance company.

What Are Medicare and Medicaid?

It seems that the public health system is always in flux. As a result, it is always a hot topic in political debate, and requirements and coverage areas frequently change. The following is a basic guide to Medicare and Medicaid.

In a nutshell, Medicare is a government insurance program for the elderly and disabled. To qualify for Medicare, you must:

  • Be over 65 and eligible for social security or railroad retirement; or
  • You must be disabled and receive social security or railroad retirement for at least two years; or
  • You must be over 65 and have Medicare coverage.

Medicare has deductibles and copayments, just like health insurance. You should choose the Medicare plan that best meets your needs from the different plans available.

Medicare Coverage
Medicare pays for a wide range of medical services, including:

  • Hospitalization
  • Long-term care facility stays
  • Visits to the doctor
  • Surgery
  • Physical therapy
  • Ambulance transport
  • Medications

Medicare, however, does not cover everything. For instance, Medicare does not cover:

  • Prescription drugs
  • Physical and eye examinations
  • Dental Services
  • Vaccinations
  • Cosmetic Surgery

Medicaid is a healthcare program funded by the federal and state governments. Medicaid eligibility varies by state, but in general:

  • The disabled
  • The impoverished elderly
  • Families with children

Medicaid Coverage
Medicaid coverage may include the following, depending on the state:

  • Services provided by hospitals
  • Medications
  • X-rays and laboratory tests
  • Long-term care facilities
  • Dental needs
  • Visits to the optometrist
  • Rehabilitation services

The Regulation of Nursing Homes

Both federal and state laws apply to nursing homes. The Nursing Home Reform Act was passed in 1987. This act ensures residents receive quality care. The act established what nursing homes must provide and the standard for these services.

These include:

  • Rehabilitation, nursing, and pharmaceutical services
  • Residents’ health is regularly assessed
  • Care plans for each resident

Nursing Home Resident’s Bill of Rights

In addition, the Nursing Home Reform Act established the Nursing Home Resident’s Bill of Rights, which includes:

  • The right to be free from abuse
  • Privacy rights
  • The right to file complaints against the home without being discriminated against
  • Respect for human dignity

Signs of Nursing Home Abuse

Nursing home abuse (elder abuse) has a few tell-tale signs, including:

  • Injuries, bruises, or bedsores
  • Excessive weight loss
  • Dehydration
  • Contaminated conditions

If you suspect that you or your loved one are victims of nursing home abuse or that the nursing home has violated the Nursing Home Reform Act, contact the nursing home administrator and file a complaint. In addition, you should contact your state agency about the violation. You can also hire an attorney to sue the nursing home for damages.

Should I Hire Legal Counsel?

If you have a health care plan dispute, it is essential to have the assistance of a healthcare attorney. Your attorney can provide advice regarding the health care laws and requirements in your area and review your existing health care policy. Your attorney can also explain the various factors involved in a health care plan and assist you with obtaining legal relief for losses you have suffered.

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