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Self-pay denial

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whimseys2000

Junior Member
What is the name of your state? RI

I was covered under a family plan (BC/BS of MA) through my husband's employer for two years and when he left the company, we switched to Cobra (initially under BC/BS HMO, then moved to a self-pay with Anthem BC/BS.) There have been no gaps in coverage.

In March (approx.) of 2003, I began treatment for infertility. RI has a state mandate that requires infertility coverage be provided and covered 100%. Everything was fine (and everything was paid in full) until the company switched to a self-insured plan. Now Anthem BC/BS is denying my claims (for services that were previously covered under the HMO). Apparently the switch happened Septemer 1, 2003 althoough due to a mess up at Blue Cross, we did not receive our new cards until the 3rd week of September. Services were rendered Sept. 5. The only notification we received from the employer was back in July which stated that "coverage will change" but not explaining it will be a self-pay or getting a new summary of benefits. If I had known that, I would have known the state mandates were no longer applicable.

Anyway, I have appealed and BC says it was the employer's responsibility to tell me they were switching to a self-pay. Is this true? Do I have any recourse or am I now stuck paying these?

Did I make any sense? :)

TIA,
Cindy
 


Beth3

Senior Member
I'm not familiar with RI reg's but it's unlikely your State has any laws that require the employer to inform employees that they have changed the "funding mechanism" of the plan - i.e. moved from fully insured to self-funded. You may contact RI's Department of Labor or the State Insurance Commission to verify that but again, it's unlikely it's required.

By the way, YOU always were the party responsible for paying your medical bills. I'm about to split a legal hair but it's an important one. The fact that there was a third party that assumed liability for some of your medical expenses does not alter the fact that you received the medical services and you were the party obligated to ensure the providers received payment. You might have a claim against an insurance carrier if they fail to pay expenses as required in your contract with them but that doesn't change the fact that the medical provider will be looking to you for payment.
 

whimseys2000

Junior Member
Beth3 said:
I'm not familiar with RI reg's but it's unlikely your State has any laws that require the employer to inform employees that they have changed the "funding mechanism" of the plan - i.e. moved from fully insured to self-funded. You may contact RI's Department of Labor or the State Insurance Commission to verify that but again, it's unlikely it's required.
I'll need to check into that w/ the DOL, but isn't it correct to say that while the employer (supposedly) did not have to inform us of funding changes, they did need to provide a new benefits summary? If they had alerted us at all that the benefits were changing that would have had a huge impact on our ability to go forward w/treatment. When we had the previous insurance I literally spent 10 hours researching coverage limitations, benefits, and mandates, and would have done the same in this instance.

Beth3 said:
By the way, YOU always were the party responsible for paying your medical bills. The fact that there was a third party that assumed liability for some of your medical expenses does not alter the fact that you received the medical services and you were the party obligated to ensure the providers received payment.
Exactly my point...if I had known there was a change in the plan, I would not have gone forward knowing full well the $$$ was going to come out of my pocket. :eek: Unfortunately, not only was there a precedent where everything had been paid in full but I didn't even know the plan had changed until February 2004 when stuff started bouncing back. I'm peeved that I was kept in the dark, if you will, when the plan changed, but I do have 6 month old twins now. (So even if I have to shut up and pay, it was worth it. ;))
 
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cbg

I'm a Northern Girl
I have one suggestion for you, based on many, many years of working with group health insurance claims in a state where infertility treatment is also state mandated. If you have already done this, please don't be insulted; it's not as obvious an answer as it might appear and many people honestly don't think of it this way.

It is quite, quite common for an insurance plan to deny infertility treatment in general, making exceptions only in states where it is required by law. I can't tell you how many times I have (in pre-HIPAA days) called an insurance carrier on behalf of an employee, to remind them that in OUR state, such treatment WAS mandated. Often a claims adjuster will automatically deny such treatment, not noticing that it was in a state where it was required.

While this does not always hold true, who is paying for the benefits does not necessarily mean that state mandates don't hold. I suggest you contact your claims office and, if you have not already done so, remind them of the state mandate and request that they reprocess.

If you have already done that, and been told that due to the change to self-insurance the state mandate does not hold, then your next step (since you have already been through the appeals process) is to file a formal complaint through the RI insurance commission.
 

whimseys2000

Junior Member
cbg,

Thanks for replying. From my research, I have discovered that RI mandates comprehensive coverage but everything I've seen says "self-insuring businesses are not required to comply with state insurance mandates." Whether that's appliacble in this situation or not, I don't know. I have appealed with BC/BS and reminded them of the state mandate. However, they never once mention it in their denial letter. They quote the exclusion portion of the benefits summary instead. I still have time to request a level 2 appeal if that should be the next step. Should I try again with them relying on the mandate to help my case?

Or should I go to the employer? When I started receiving the initial "you're not covered, we're not paying" letters, I called the employer (for whom my husband no longer works) and they had no idea if the mandate applied to them.

I emailed the Department of Labor and was given a number for the Division of Labor Standards, who should be able to provide labor laws and regulations. A third option would be just to bypass the above and file a formal complaint through the RI insurance commission.

What do you think? (And thanks very much for helping)
 

Beth3

Senior Member
Self-insured group health plans quite often are exempt from complying with State mandates because a self-funded plan isn't actually an "insurance plan" as defined in the law - although from the employee's perspective it certainly looks and feels like one.

I'd suggest you contact RI's Insurance Commission to find out if the employer has any liability for the expenses if you were not notified timely that these types of expenses were no longer covered by the Plan.
 

whimseys2000

Junior Member
Bumping this...

Received a phone call today from Anthem RX wanting to know when I was going to pay the outstanding balance on my account (was told back in May they weren't going to pursue it but I guess they changed their minds as tax time rolls around.)

Anyway, I happened upon a RE's site today and he spoke of infertility as being a disability. That led me to eeoc.gov which has a lot of info about the Americans with Disability Act. I'm curious if you senior members think this will be helpful for my case as well as others struggling with coverage.

Beth3, this goes hand in hand with your statement about employer responsibility, I think.

http://www.eeoc.gov/policy/docs/health.html

>> The ADA also prohibits employers from indirectly discriminating
on the basis of disability in the provision of health insurance.
Employers may not enter into, or participate in, a contractual or
other arrangement or relationship that has the effect of
discriminating against their own qualified applicants or employees
with disabilities. 42 U.S.C. § 12112(b)(2); 29 C.F.R.
§ 1630.6(a). Contractual or other relationships with
organizations that provide fringe benefits to employees are expressly
included in this prohibition. 42 U.S.C. § 12112(b)(2); 29
C.F.R. § 1630.6(b). This means that an employer will be liable
for any discrimination resulting from a contract or agreement with an
insurance company, health maintenance organization (HMO), third party
administrator<<
 

cbg

I'm a Northern Girl
If you're planning to invoke the ADA as a part of this, there are a few things you'd better know pretty quickly.

1.) There is only ONE condition that is AUTOMATICALLY considered protected under the ADA, and that is HIV/AIDS. Each and every other condition, WITHOUT EXCEPTION, has to be looked at on a case by case basis.

2.) Accomodations under the ADA have to be agreed on BEFOREHAND. You don't get to go back afterwards and claim a disability and sue for the lack of an accomodation you never asked for.

3.) You don't get to decide what accomodation you get.
 

whimseys2000

Junior Member
cbg said:
There is only ONE condition that is AUTOMATICALLY considered protected under the ADA, and that is HIV/AIDS. Each and every other condition, WITHOUT EXCEPTION, has to be looked at on a case by case basis.
I have seen documentation to that effect, no surprise there. :)

2.) Accomodations under the ADA have to be agreed on BEFOREHAND. You don't get to go back afterwards and claim a disability and sue for the lack of an accomodation you never asked for.

3.) You don't get to decide what accomodation you get.
Can you flesh this out for me? I'm not sure what you mean. Infertility is considered a disability, no? If so, it should be covered under the ADA and therefore the quote I pasted above should apply re: employer reimbusement/liability.

"This means that an employer will be liable
for any discrimination resulting from a contract or agreement with an
insurance company, health maintenance organization (HMO), third party
administrator."

If I'm way off base here,feel free to tell me! :D
 

cbg

I'm a Northern Girl
You're not WAY off base, but you're slightly off base.

First off, you're making an assumption that you can't make. You're assuming that in ALL cases, infertility is a disability. But that's what my first point was all about. With the sole exception of HIV/AIDS, NO condition is granted automatic protection under the ADA. In ALL other cases, INCLUDING infertility, it has to be looked at on a case by case basis. And that doesn't mean looking to see if infertility is a disability, or even if infertility is a disability in Rhode Island. It means looking to see whether or not Whimseys2000 is disabled due to infertility under the ADA. Anyone who tells you that infertility is ALWAYS a disability under the ADA, doesn't know how the ADA works.

Then, you're assuming that because ADA CAN BE considered a disability, then the insurance company is REQUIRED to pay for it. That's not the case either. Let's say you have a condition that requires speech therapy, and your employer's health insurance plan covers speech therapy. They can't turn around and eliminate speech therapy for the purpose of keeping you from getting treatment. But if speech therapy was already excluded, it's not discrimination if they refuse to modify the policy to pay for it.

For the purpose of explaining points 2 and 3, I'm going to take it out of the insurance area and use examples that are a bit easier to follow along with.

Suppose you have a condition that makes it difficult for you to get up in the morning. Maybe depression, maybe sleep apnea, whatever. You never tell your employer about it, but you're frequently coming in late. Your employer is justifiably annoyed with you, and sooner or later, after giving you several warnings, he fires you.

You turn around and say, "You can't fire me. I have (name of condition) and you have to accomodate my condition by letting me come in late".

Well, you're wrong on two different counts. First off, since you never told your employer that you have (condition) he has no obligation to accomodate you. There have been plenty of court cases in which it's been determined that the employer has no responsibility to accomodate a condition he's never been notified of ahead of time. It's legal, in this case, for him to fire you, regardless of whether you have a condition that might qualify under the ADA or not.

And secondly, even if he decides to forgive you and hire you back, he doesn't have to give you the accomodation you want. There are other options. If he doesn't want to let you come in late, and instead wants to change you to second shift so you don't need to be in till 3:00, he's still accomodated your condition. You don't get to choose your accomodation, and he's not even required to give you the accomodation your doctor recommends. All he has to do is give you an accomodation that works.

But, as I said, he doesn't HAVE to accomodate you if you didn't give him fair warning ahead of time. You can't make the need for an accomodation retroactive.

Clearer now? If not, let me know and I'll try again. This can be tough to follow.
 

whimseys2000

Junior Member
Perfectly clear, thank you. I've done some more reading too and see that cases have been dismissed because this benefit is either offered to all covered or none, therefore no one is being discriminated against because the coverage is the same across the board.

However...:D...does the fact that this was an ongoing treatment and the precedent was that everything was completely covered mean anything? Maybe I should just contact the RI Insurance Commission and continue on that road?

BTW, I appreciate all the info and time you've spent trying to help me. ;)
 

cbg

I'm a Northern Girl
I think you're better off going with the insurance commission. Just because a benefit is offered initially, doesn't mean the employer has to continue offering it forever. It's no different than if he was offering tuition reimbursement, and decided to no longer offer it. The law isn't going to require him to offer it in perpetuity, just because he offered it once. To get anywhere on the discrimination issue, you'd need some evidence that the employer decided against covering infertility BECAUSE OF your treatment, and that's going to be a very high standard for you to meet.
 

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