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Know your health care rights? Here are some quick tips

Members of the Massachusetts Bar Association's Consumer Advocacy Task Force provide video tips about health care rights.

*HEALTH CARE

Helpful Tips

Here are some tips and information, which address some of the most frequently asked questions regarding health care coverage in Massachusetts:

 


Useful Resources

The Massachusetts Bar Association's Consumer Advocacy Task Force recommends that consumers visit the following websites containing supplemental information concerning health care coverage:

Massachusetts Attorney General's Office, Health Care Division

The state's AGO division website dedicated to promoting consumer issues related to health care. This page contains substantive information related to quality of care complaints, tips on purchasing health insurance and veterans' assistance.

Massachusetts Office of Patient Protection

State website for consumers seeking to file grievances or external reviews regarding health insurance claims decisions.

United States Department of Labor, Consumer Information on the Affordable Care Act

U.S. Government's website dedicated to the Affordable Care Act, which includes helpful information related to health care coverage for you and your family, continuation of coverage and required benefits and programs.

United States Department of Labor, Know Your Health Benefits Rights

U.S. Department of Labor video detailing general health benefits rights.

United States Department of Health & Human Services, Health Information Privacy

U.S. government's website containing information related to consumer privacy rights and health care records. The site also contains detailed explanation of the Health Insurance Portability and Accountability Act ("HIPAA").

 


Helpful Tips

Am I required to have health insurance?

As of 2007, all adult Massachusetts residents are required to have health insurance. Residents must verify and confirm their health insurance coverage on their tax return, and residents who do not have health insurance could potentially face monetary penalties. If you need assistance obtaining health insurance, the state has created the health connector website which offers services related to applying for medical coverage and obtaining required verification forms.

What if I disagree with a coverage decision?

It is possible that you have encountered an issue regarding your health plan provider's refusal to cover certain medical costs or procedures. If you contacted your health insurer or plan provider with a complaint or grievance, note that Massachusetts Law does not require you to provide such grievance in writing. The provider must accept grievances by phone, mail, in person, or electronically (by fax or email).

If you have filed an internal grievance with your health plan provider regarding claims decisions, Massachusetts Law requires your provider to provide you with a written decision or resolution of your grievance within 30 business days. State law does not allow your provider to delay its internal grievance review without your permission, in writing.

Do I have any recourse outside of my insurance company or health plan provider?

The Massachusetts Office of Patient Protection provides an avenue for residents to file grievances and seek external reviews regarding health insurance claims decisions. If you believe that your health plan provider has improperly reviewed your grievance or otherwise improperly refused coverage, you should visit the Patient Protection website

Additionally, if you are having problems with your health insurance claims or medical bills, the Attorney General's Office Health Care Division might be able to assist you. There, you can submit a complaint, describing the issues you are experiencing with the claims handling company and what steps you have taken to resolve the issues. Make sure to keep track of all letters and documents you have sent to the insurance or claims handling company.

Can I or my children be denied for a pre-existing condition?

In Massachusetts, certain protections are in place to assist residents and their children in obtaining health insurance coverage. Children under age 19 with pre-existing medical conditions may not be denied access to their parents' health plan. Further, insurers in Massachusetts cannot reject health insurance applications on the basis of pre-existing medical conditions; however, insurers may impose a pre-existing exclusion period for up to 12 months upon individuals who did not have prior continuous coverage.

How private is my medical information?

It is important to know that Federal Law under HIPAA provides protection of your personal health information. Health care providers are obligated to properly secure and protect your medical records. If you believe your personal health information is being improperly disclosed, you should contact the Massachusetts Office of Patient Protection.

What are copayments, deductibles and coinsurance-how do they differ from one another?

A copayment is a fixed dollar amount paid by the insured directly to a doctor, hospital, pharmacy or other health care provider at the time he or she receives a covered service. A plan may have different copayments for different types of covered services. For example, the copayment for a primary care visit may be $20 and for an emergency room visit may be $150. Copayments are very common in managed care plans (such as HMOs and PPOs) and in drug plans such as Medicare Part D.

  • Deductible: A deductible is the initial yearly amount that the insured owes for health care services before the health insurance or plan begins to pay. The deductible may not apply to all services. The deductible amount does not include the premiums paid for the health insurance policy. The deductible is often chosen by the employer or the insured. Usually if the deductible is low, the health insurance premium is higher.
  • Coinsurance: Some health insurance plans require that the insured pay a percentage of the allowed amount of covered health-related services, even after meeting possible copayments or a yearly deductible. This is known as coinsurance. Often the coinsurance percentage which is paid by the insured is about 20-30 percent of what the health plan approves. The health plan pays the remaining 70-80 percent of the medical charges.

Can my application for individual or family health insurance coverage be declined?

Massachusetts law prohibits insurance policies from excluding individuals based on age, occupation, health condition, claims experience, duration of coverage or medical condition. Late enrollees may not be excluded from a health plan for more than 12 months.

Can I buy health insurance from one state and use it in another state?

It depends on whether the insurance policy which is being considered provides coverage in the other state. The individual plan documents would need to be consulted.

What is HIPAA?

HIPAA is short for the Health Insurance Portability and Accountability Act of 1996. It is a federal law intended to improve the efficiency and effectiveness of the health care system. Two important parts of HIPAA are the Privacy Rule and the Security Rule. The Privacy Rule provides protections for patient's personal health information and gives patients an array of rights with respect to that information. At the same time, the Privacy Rule is balanced so that it permits the disclosure of personal health information needed for patient care and other important purposes. The Security Rule specifies a series of administrative, physical and technical safeguards that must be used to assure the confidentiality, integrity and availability of electronic protected health information.

*These answers do not constitute legal advice and are written for general information purposes only. Individuals should consult with a lawyer for specific legal advice.

If you have any questions concerning these topics or other consumer protection issues, we highly suggest that you contact the Massachusetts Bar Association's Lawyer Referral Service. Get an instant online referral here. Or call us to speak to an LRS representative* (Mon.-Fri., 9 a.m. - 4:45 p.m.) at (617) 654-0400 or (866) 627-7577.

 

 




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