Frequently Asked Insurance Questions

Insurance FAQs

How do you track cases as they are being underwritten?

New cases are added to the system and assigned an account number. Cases can be referenced via this number or by company name and are monitored by our note system (which underwriter received it, to which underwriter it was assigned, etc.).

Can I obtain any effective date for coverage?

Most carriers offer the 1st or the 15th of the month only.

Is payment required with enrollment materials?

Yes, at least one-month’s premium.

Are cases automatically denied for incomplete paperwork?

No we will contact the agent and will hold cases for 10 days pending receipt of outstanding material. Thereafter cases are returned to the agent and copies are retained in our files.

What are the most common grounds for case denial?

Lack of or unacceptable tax documentation; not meeting participation requirements.

How does the appeals process work?

Once denied, copies of the appeal materials are sent to the carrier who then submits to the Appeals Committee for review. Appeals take approx. 3 weeks for a final decision.

What tax documents are acceptable for qualification?

(address filing extensions/last return filed etc.) One-man groups require at least two forms (Sched C & SE) whereas 2+ groups would require either a NYS-45 (most recent quarter), 1120S, 1065 and Schedule K-1s.

What is re-qualification?

An annual review of a subscriber company’s tax documents to verify company is still an active business and all eligible/covered employees are still listed on the documents.

What is a Letter of Certification?

A Letter of Certification is a form letter that allows for a CPA or attorney to attest to the active and/or employment status of a company and/or individual applying for coverage.

Why do I need to sign a Late Paperwork Form?

New enrollments can and will be accepted beyond the “5-day-prior-to-effective-date-cut-off”, but will require written verification that the client is aware there will be a delay in issuing their ID cards.

How does my group meet Dependent Student Requirements?

Student above the age of 19 are required to attend school full-time earning at least 12 credits per semester. Parents may complete the new Student Verification form – it is no longer necessary for the school to attest to a student’s status.

Do I really need a Case Submission Coversheet?

This is primarily a question for insurance agents submitting enrollments on behalf of their clients. Agents must use a Case Submission Coversheet so that the particular enrollee is properly associated with the correct insurance agent. This is particularly important if there is missing or incomplete enrollment information.

How do I make a plan change for a group?

Plan changes are made on a group’s enrollment anniversary date by submitting a Plan Selection Form. Plan changes that create an INCREASE in benefits are considered a “buy-up” and can only be made on a group’s anniversary. However, plan changes that create a DECREASE in benefits are considered a “buy-down” and may be made at any time before reaching the point of being 90 days prior to a group’s anniversary date.

What is a "buy-up" or a "buy-down"?

Plan changes that create an INCREASE in benefits are considered a “buy-up”. Plan changes that create a DECREASE in benefits are considered a “buy-down”.

Can my group be reinstated for non-payment of premium?

Reinstatement for non-payment of premium can occur only once per policy year. Should a second cancellation for “non-payment” occur within the policy year, the group must wait 12 months before they will be permitted to re-enroll.

Can my group be reinstated retroactively?

In most cases the answer is “yes”, however, retroactive reinstatement is always subject to carrier approval.

How do I add a new employee?

Adding new employees to an existing group is easily done. Once new employees have satisfied the group waiting period (chosen by group upon initial enrollment; usually 30, 60, or 90 days), a group can then simply submit an individual enrollment application listing the employee’s date of hire and related information. This will document that they have satisfied their eligibility waiting period and provide us with the information needed to activate the new employee on the coverage.

How do employer waiting periods work?

A group usually selects a waiting period of 30, 60, or 90 days. New employees are eligible the 1st of the month following the last day of the waiting period (i.e. an employee has satisfied their waiting period on Sept. 20th. They will become active on the insurance plan on October 1st.)

Must every potential insured own a business?

Business ownership is required when purchasing a GROUP health insurance policy (in the NYS “community-rated” segment, group products are almost always broken down into “groups of 1” or “groups of 2-49”. Groups with 50 or more employees are eligible for an “experience-rated” policy). There are policies available to individuals that cannot obtain benefits through their employer, work too few hours to be eligible, are non-dependent students, are in the midst of their employer waiting period, or fall into a classification not addressed by group underwriting guidelines.

Can a business with employees outside of NYS obtain coverage for everyone?

As long as the business is domiciled within NYS and has at least 80% of its employees living or working in NYS, that group can enroll all of its employees in most NYS insurance carrier plans (often referred to as the “live/work” rule).

Can 6-month coverage be written for "snow-birds" or individuals with dual residences?

Yes, as long all tax (corporate) files list a New York address.

Can my group terminate coverage retroactively?

Yes, when they can provide proof of duplicate coverage. The normal limitation is up to 45 days.

Do I need to include my prior carrier statement w/new business submission?

It is helpful, but not mandatory. Carriers will request it at a later date to finalize the waiving of any pre-existing condition clauses.

How long does it take to get a new case approved?

Approximately 5 business days.

When will the approval letter be issued?

The day after case is approved.

Why is there a five-day new business submission rule?

Carriers usually require a minimum of five business days to review and approve new cases. Approval is not guaranteed.

What is the time frame from approval to when ID cards are mailed?

7 to 10 business days.

Customer Service FAQs

I don't have my ID cards—how do I access coverage?

Your individual certificate of insurance number/coverage information can be obtained from your respective carrier and can be used to access coverage or fill prescriptions.

My ID cards are wrong—what do I do?

Simply report the problem to the carrier or CAI Customer Service. New cards will be ordered and issued. Typographical errors rarely affect the ability to access coverage.

What is a pre-existing condition?

A pre-existing condition is any condition which you have been treated for prior to securing insurance coverage. If you did not have prior insurance coverage while being treated for this condition you will be subject to a waiting period before any benefits can be received for treatment related to that condition (most insurance carriers enforcer a 12-month waiting period). If you had continuous coverage prior to switching plans (less than 63 days without coverage), any time spent covered can be credited towards the waiting period.

How do I submit a claim and how long do I have to submit the claim?

Most every claim will require a paper or on-line claim form that documents any treatments, care, lab services etc. Most carriers will require that claim forms be received within 6 months of the date of service.

How does the claims-appeal process work?

Every insurance carrier will have a Grievances & Appeals department. Appeals are reviewed by a medical board of directors for a determination on whether the initial “not covered” decision should be overturned or some level of benefit should, in fact, have been provided.

How does COBRA work?

C.O.B.R.A (Consolidated Omnibus Budget Reconciliation Act) provides you the ability to continue to pay directly for your coverage for up to 18 months (or 36 months for dependent students, divorce, or death). The subscriber usually pays the employer or group administrator that benefits were initially secured through.

What are the rules for dependant coverage?

Under the new laws, dependants are covered until the end of month of their 26th birthday. An optional rider can be purchased to extend this coverage through age 29, valid until the end of the month of their 30th birthday, although certain restrictions apply. This applies only to plans with an anniversary date after October 2010. If your plan has not had an anniversary after October 2010, the dependant rules the plan was created under are still in effect.

What is the Dependent Student procedure?

Plans prior to October 2010 required a Student Dependent Form attesting that the dependent is still in enrolled in school, and must be filled out and submitted periodically (most often twice a year). Plans with an anniversary date that has passed after October 2010 are covered under the rules described above

What is a specialist copay?

A specialist co-pay is most often whatever your regular physician copay is. However, a consultation charge of $15.00 (in most instances) for a first time consultation with the specialist can be added.

I'm covered 100% out-of-network, why am I receiving a bill?

Out-of-network coverage is most often subject to an out-of-Network deductible (typically $250, $500, $750, $1000 or more). In a “100% out-of-network coverage” scenario, after your deductible is satisfied there could still be a balance billed to you. This happens because the “100% coverage” represents what the carrier will allow or finds reasonable and customary. According to their schedule of Maximum Allowable Charges they are, in fact, paying 100% of the benefit allowed. However, that amount may not match up with 100% of the total charges from the physician, lab, or facility.

What is a percentile and what is HIAA?

A Percentile works essentially like it sounds: a percent. HIAA, the Health Insurance Association of America, provides information that helps insurers determine their plan allowances for their covered services. You may be enrolled in a plan that reimburses at the 70th, 80th, or 90th percentile of those pre-determined allowances.

How does mail order pharmacy traditionally work?

A Mail Order Pharmacy Program is designed to provide maintenance prescription services. Usually a s subscriber can obtain 90 days worth of prescriptions at a 60-day cost savings. The subscriber obtains a 90 day prescription from their physician and submits it to the insurance carrier Prescription Benefit Manager (PBM). The PBM then mails the prescription to the subscriber. It is the subscriber’s responsibility to obtain the prescriptions from their physician and place orders/re-orders before they run out.

What's a mandatory generic prescription requirement?

A mandatory generic prescription requirement is a cost-saving measure designed to limit expensive prescription costs. If there is a generic equivalent to particular brand-name prescription you must have the generic filled in order to be covered. You can usually obtain brand prescriptions at a higher level (or perhaps out-of-pocket depending on your plan) should the physician indicate “dispense as written”.

What is an in-network deductible and when does it often apply?

In-network deductibles are a relatively recent trend in healthcare benefit delivery. They are designed to help keep monthly rates low while still providing benefits for some of the more costly services (such as ambulatory surgery, surgical procedures performed in doctor’s office, or labs charges from a hospital facility) even though they were administered by in-network providers. Only specific plans have in-network deductibles and will clearly indicate so.

What are "hospital facility charges"?

Hospital facility charges are normally costs that are covered under the hospital-specific portion of a health care plan or a “hospital-only” plan. They pertain to certain “room and board” charges, in-hospital administered drugs and solutions, nursing care, certain substance abuse treatments, mental and nervous admissions and care, pre-admission testing, diagnostic admissions and more. They normally do not describe physician care, lab facility, surgical and anesthesia costs.

Is all emergency care covered?

Most every insurance carrier will cover emergencies. Be sure to understand your benefits as they relate to out-of-state or international emergencies. Also, emergency room coverage is distinct from coverage once (if) admitted to a hospital facility.

Is ambulance and/or air ambulance service traditionally covered?

Some type of coverage is traditionally provided toward the expense of an ambulance trip. However, the entire cost is rarely covered. More insurers are providing benefits for air ambulance trips, but know that it is a costly expense and perhaps only covered by certain plans or even an additional rider. Again, coverage for the entire cost is unusual and most carriers will not cover air transports from one hospital facility to another.

Am I covered for emergencies out of state? Internationally?

Out-of-state and International coverage is limited to a PPO plan type (In/Out-of-Network benefits). All bills must be in English and American currency. An EPO plan (in-network only) will cover you for specified emergency room charges, but once admitted (under an EPO plan) subscribers are out of benefit. Emergenices treated by out-of-state physicians (via the National MultiPlan network) could be covered, but coverage details of this and related scenarios will refer back to the certificate of insurance.

I was admitted to a participating hospital but received bills from various physicians and tests. Why?

The most common reason for this is that the billing physicians are out-of-network (they are non-participating and not employees of the hospital). Some labs working with/through hospitals simply don’t participate in any insurance plans. It is always best to request in-network providers and services whenever possible.

What is pre-certification and why is it necessary?

Pre-certification is a procedure used in managing care and costs. Some of the more expensive tests, procedures, and surgeries will require pre-certification. In pre-certifying you are letting the carrier know of your intention to access care under their plan. They review and asses the medical necessity and either authorize or deny coverage. You can, of course, pay for any denied procedures yourself, or appeal the decision (your physician can provide more information as to why he/she ordered the procedure).

What does the term Coordination of Benefits mean?

Coordination of Benefits is the process of determining what coverage is applied as the primary coverage in situations where multiple carriers or polices are involved. For instance, if you have Medicare parts A & B, Medicare will be primary and your supplement coverage would be secondary.

When do I qualify for Medicare?

Medicare is for all subscribers that have reached the eligible age or experienced a disabling event (or other applicable qualifying event) that entitles them to qualify for coverage. A disabling event can occur anytime after the age of 18, while retirement eligibility can occur as early as age 62. Applying for Medicare parts A & B (hospital/medical) and perhaps a Medicare Supplement (to pick up some of the remaining costs) is a common practice.

I'm retired; what serves as my primary coverage Medicare or my group policy?

Medicare, once eligible and enrolled, will always serve as your primary coverage from that point forward. Many people supplement their Medicare coverage with a supplement policy or senior carve out plan (those plans will pay submitted claims “secondarily”).

How do I avoid expensive diagnostic imaging costs?

The most important step you can take is always ask about using in-network providers or facilities that participate in you carriers insurance plans. MRIs and CT-Scans can be very expensive, especially if you have to pay out-of-pocket for them. Check your list of participating facilities, labs, hospitals and the like (while a hospital may be “in-network” it is best to confirm that the diagnostic systems/technicians are also participating. Often, pre-certification for these services is required. The insurance carrier can assist you with advice and direction at that point).

My physician is non-participating; can they become participants?

Yes, if they are willing to participate. All insurance carriers have a provider relations department that is always looking for new plan participants to increase the size and scope of their in-network benefits. However, in order to participate, the physician or facility needs to be willing accept the carrier’s reimbursement schedule/agreement as payment for services rendered.

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