PRIVATE
INSURANCE is either provided by your employer or obtained
on your own. In either case, you may contribute entirely
or in part for the cost of the premium. Private insurance
plans are governed by NJ law and are enforced, depending
on the issue, by the NJ Departments of Health & Senior
Services Office of Managed Care (DOHSS/OMC) and Banking
& Insurance (DOBI). Beneficiaries of private, managed
care plans are afforded three levels of appeal - two internal
appeals within the insurance plan and a third external review
before an Independent Utilization Review Organization (IURO).
The IURO decision is binding on all parties. DOBI reviews
billing disputes and mental health parity issues.
PUBLIC
ASSISTANCE coverage includes Medicaid (fee-for-service,
Early Periodic Screening Diagnosis and Treatment Program,
managed care, or Waiver Programs) and Medicare coverage.
The various forms of Medicaid coverage and Medicare require
more discussion than this article allows. In short, Medicaid
is a federal-state entitlement program for low-income Americans.
Medicare is a partner program to Social Security, which
provides a health and financial safety net to those 65 years
and older and to those declared disabled for 24 months.
There are individual eligibility requirements for these
public assistance programs and they all provide different
(or additional) appeal rights than the other forms of insurance.
STATE HEALTH BENEFITS PLANS (SHBPs) are provided to individuals
who are employees of the state. This coverage is similar
to private employer-provided plans in that it is a benefit
of employment. Unlike private insurance however, SHBPs are
self-administered medical plans that are not subject to
the jurisdiction or control of NJ's Departments of Health
& Senior Services and Banking & Insurance, nor are
they subject to the jurisdiction of the U.S. Department
of Labor. Therefore, SHBPs have greater leniency in what
they cover (or not) and for what duration because they are
not subject to NJ’s insurance laws. Like private,
managed care insurance, SHBP beneficiaries have two internal
appeal levels; but the third external appeal level is before
the State Health Benefits Commission (SHBC). The decision
of the SHBC is final and appealable to the Office of Administrative
Law (OAL).
SELF-FUNDED/-INSURED
PLANS are insurance plans offered by a private employer
in which the employer assumes the financial risk of insuring
its employees. Under most employer-provided plans, the employer
pays premiums to an insurance company, which assumes the
risk of insuring the employer’s employees and administers
the plan (and handles all of the claims). With self-funded
plans, the employer hires an insurance company to administer
the plan and handle all of the claims (since it is the insurance
company and not the employer, typically, that is in the
business of administering insurance). As with the SHBP,
self-funded plans have greater latitude as to what the plans
do and do not cover. Appeals under such a plan must be filed
with the U.S. Department of Labor - not internally with
the insurance company or externally with the NJ Department
of Health & Senior Services Office of Managed Care.
It is, therefore, important to examine the inside cover
and the appeals rights section of your member handbook to
determine whether you have this type of plan.
Understanding
your insurance coverage will assist you to maximize your
health care benefits and understand your responsibilities
and rights under the plan.
©2004
Copyright
