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Getting the Scoop on Common Coverage Misconceptions
When employees understand their total compensation package, chances are they'll not only appreciate the value of their employer's investment, they'll also take full advantage of the benefits.
When a company educates its employees about health insurance, retirement programs, health savings accounts and supplemental life insurance, those employees are able to make informed decisions about those benefits.
Decoding the packages
Health insurance packages, and the "rules" related to particular policies, are the most important and the most confusing benefits for employees and their families. That's why health coverage information packets aren't enough. Employers need to help employees understand their coverage by educating them about what medical services are – and aren't – covered.
Employees often have misunderstandings about these issues:
- If a company provides health insurance through a managed care plan, enrollees must use physicians and hospitals that are part of the plan's approved "network." Employees using "out-of-network" providers need to understand their insurance may not cover the costs of services and they may be responsible for the bill.
- If an employee needs to see a specialist, many plans require the enrollee to first visit a primary-care doctor and receive a referral. If an employee sees a specialist without a referral, he or she may have to pay more out-of-pocket costs.
- Insurance companies often require pre-authorization before paying for surgeries or tests. They may not pay the costs if the medical treatment hasn't been pre-approved.
- Most insurance companies also use an approved drug formulary for prescription medicine. If an enrollee is prescribed a drug not on the formulary, the employee will have to pay more for the medicine. Employees should share the formulary with their doctors to avoid these extra and often unexpected expenses.
Confusion with HIPAA
Employees aren't the only people who get confused. Employers may still be confused about Health Insurance Portability and Accountability Act (HIPAA) regulations that relate to privacy obligations to their employees.
The Privacy Rule is meant to protect all individually identifiable health information. It sets basic privacy standards and fair information practices that give people a basic level of protection related to their health and medical care.
Here are some common misunderstandings about HIPAA guidelines:
- All employers who offer group health plans to employees should determine their compliance obligations, even though the insurance provider administers the benefits. The only exception is for very small (fewer than 50 participants), self-administered group health plans.
- Even if an employer's group health plan does not transmit electronic health information, the business is not exempt from the HIPAA regulations.
- Both the employer and the group health insurance provider must ensure HIPAA compliance. Any health information a company receives about an employee is limited to "summary health information" and can only be used according to the privacy rule.
- Flexible Spending Accounts are also subject to HIPAA, even if the company is not directly involved in administering the plan.
- When a third-party administrator verifies that a health plan is in compliance, the employer still has a legal obligation to comply and should take pro-active steps to ensure compliance with the law.
- Companies that don't receive health information about their employees are relieved of some compliance obligations, but not all of them. This is because self-insured or fully-insured employers may still be receiving protected health information. It is the company's obligation to make sure it complies with HIPAA.
HealthQuest helps with medical management related to health care benefits and much more. To learn more about customized and effective solutions, contact our business development professionals at 1.800.222.077, or visit www.healthquestservices.com. |
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