9

This is "Topic #601" in various ForwardHealth interpretative statements about BadgerCare Plus and Medicaid. The last 3 paragraphs say: When commercial health insurance plans require members to use a designated network of providers, non-network (i.e., providers who do not have a contract with the member's commercial health insurance plan) will be ...


6

From healthcare.gov: How premiums are set Under the health care law, insurance companies can account for only 5 things when setting premiums. Age: Premiums can be up to 3 times higher for older people than for younger ones. Location: Where you live has a big effect on your premiums. Differences in competition, state and local rules, and cost of living ...


5

It is legal for a dentist to bill you for services rendered. You have an obligation to pay the dentist (in exchange for services); the insurance company has an obligation to cover certain expenses of yours (in exchange for money); the dentist has an obligation to the insurance company to accept certain terms specified by the insurance company (in exchange ...


5

The health insurance contract should set forth what is and is not covered in detail (in addition, there would be a short summary version). They probably don't have to provide procedure codes that are covered or not covered because no such one to one correspondence exists because the language of the insurance contract is controlling and does not exactly ...


5

Is it legal for a company to offer a different insurance rate based on the spouse's employer's offerings? Given the scenario you describe, your employer is not charging you a different rate if your spouse is eligible for insurance from your spouse's employer. Under the Affordable Care Act, when an employer decides to provide health coverage to their ...


4

If I may paraphrase the scenario: The customer has a contract with the insurer The customer is contemplating undergoing a certain procedure and is unsure if it is covered under the contract The customer calls the insurer to ask this specific question The insurer says "yes" The customer undergoes the procedure The insurer refuses to pay on the ground that it ...


4

This practice is known as "rescission". It is legal under 45 CFR §147.128 in some circumstances. The regulation says (a) A group health plan, or a health insurance issuer offering group or individual health insurance coverage, must not rescind coverage under the plan, or under the policy, certificate, or contract of insurance, with respect to an ...


4

Yes, the law can make such limits For another common example, an unlicensed person often cannot enforce payment if they carry out building work performed that requires a licence. It's worth being clear here - it's not unlawful to ask for payment provided that it's made clear that the person being asked has no obligation to pay. If a person who was not ...


3

In the US, people are generally allowed to charge arbitrary amounts for services, as long as they do not violate various anti-discrimination laws in doing for. For example it would be illegal to charge people of one race less than they charge people of another race, because of federal and state anti-discrimination laws. Three primary factors govern the ...


3

It is legal and quite common. Your choice as consumer is at the point of selecting insurance company. If you dislike ES enough, that would be a reason to select a different insurance company. It would be surprising if your ES contract disallows pharmacy pick-up, but even if it did, that would also be legal. This does not mean that the government doesn't ...


3

Suing relatives or friends to trigger an insurance policy is sometimes necessary, particularly if the insurer is being recalcitrant. Apart from that it is pointless to sue someone who has no money! In common law jurisdictions you can of course sue anyone for negligence. One of the things that you have to prove to be successful is that the defendant owed a ...


3

You can refuse to pay. The doctor can either accept your refusal or pursue the debt in court. If he pursues the debt you will probably lose. The Common Law position Your contract with the doctor was for him to do whatever he did and you to pay for it. Your contract with your insurer is for you to pay the premium and them to reimburse you for whatever they ...


3

I'm going to go out on a limb somewhat and say that claims made by a customer service representative are not binding, and are only advisory. The reason is that the company is only bound by the terms of your agreement with them. It is possible to change the terms of a contract, but especially with an oral change there would be a substantial challenge in ...


3

The concept of "controlled substances" has a special meaning, and stems from the Comprehensive Drug Abuse Prevention and Control Act of 1970, resulting in Chapter 13 of Title 21. Ordinary presecription drugs are the result of an older act, the Federal Food, Drug, and Cosmetic Act, which is also implemented in Title 21. The basic distinction is the difference ...


2

They're not actually billing people different amounts because they have insurance or not. Doctors can pretty much bill a patient whatever they want for their service, similar to how a grocery store can charge whatever they want for their fresh deli cheese. Generally, they charge every single person the same amount. It just gets discounted depending on the ...


2

As they say, a pre-existing condition is one that was existing at the time you applied for and were given insurance. A pre-existing condition may be known or unknown: insurance will generally cover unknown conditions (e.g. congenital defects, undiagnosed diseases), and this seems to be what they are saying . Known conditions are generally 1) not covered 2) ...


2

Insurance law varies from state to state and policies have widely varying language. What your insurance company is bound to [as it refers to their obligations to you to cover charges] is the language in their contract. Without providing a lot more information, all you can get here is some very general information that may or may not apply. There are ...


2

Your analysis is correct. Hobby Lobby would be irrelevant insofar as health benefits are concerned (although the general religious objection doctrine would still have relevance in other contexts, e.g. pharmacy operators), in a Medicare for all single payer system where health insurance did not involve an employer. And you are likewise correct that a ...


2

The "shared responsibility payment" is a tax and not a fine, at least according to parts of the Supreme Court ruling on the matter (National Federation of Independent Business v. Sebelius, 567 U.S. 519). Under Executive Order 13765, departments of the executive branch were allowed to "exercise all authority and discretion available to them to waive, defer, ...


2

Parents have a legal obligation to care for their minor children: it is illegal to harm a child through action or inaction. State law and associated welfare programs are complex: you can start here. If surgery is medically necessary, her insurance should cover it. If her parent do not have medical insurance, they still have the obligation of care; though ...


2

Setting up any health insurance plan is subject to myriad state and federal regulations and is not something anyone should embark upon without a lawyer. There are private for profit and non-profit health care arrangements that exist now, and more can be created, but they must comply with all relevant laws. A ballpark minimum legal cost to set something like ...


2

The "Privacy Rule" of HIPAA would prohibit this from happening. §164.504(f)(2)(ii) imposes requirements on group health plan documents (agreements), which must Provide that the group health plan will disclose protected health information to the plan sponsor only upon receipt of a certification by the plan sponsor that the plan documents have ...


2

It isn't obvious on the face of it whether health decisions means "treatment decisions in non-emergency situations" or also includes choices of health insurance plans. Both of these could be fair readings of the language and it wouldn't be unusual for the relevant documents to simply be ambiguous on this point. This would depend to some extent on whether ...


2

The general answer in the US is that insurance is a state-regulated business, so insurance companies cannot just do whatever they want. Here is a central resource for Washington state. In general, if a person is "risky", the carrier can raise premium cost, and eventually can decide that the risk is too high. E.g. I cannot get earthquake insurance because of ...


2

The at fault driver (in a state that is not a "no fault" state) has a legal obligation to pay all of your medical bills and all other economic and non-economic harm to you caused by the accident in which the other driver is at fault (without regard to whether you paid it out of your own pocket, or your insurance company or other third party did). This right ...


2

What fraud would I or the provider be committing? None. Their conclusion reflects their cluelessness about the prima facie elements of fraud. Since the insurers already declined coverage, the only person that could have standing to sue for fraud is you. And clearly you don't intend to proceed against the provider. The insurer has no viable claims [against ...


2

To piggy-back off of user6726, I found some supporting materials regarding what's going on: Topic #213 - Sanctions for Collecting Payment From Members Under state and federal laws, if a provider inappropriately collects payment from an enrolled member, or authorized person acting on behalf of the member, that provider may be subject to program sanctions ...


1

This is discrimination. HOWEVER, in the US, discrimination is by default legal, unless it is due to one or more specific enumerated characteristics. Being insured is not a protected class; as such, it is legal to discriminate on price based on whether someone is insured or not.


1

You have a contract with your employer's medical insurance, whereby they will cover your expenses from this accident; following the most likely terms of that agreement, you have to cooperate so that they can get money from the other involved parties (the drivers). Since the other drivers have insurance agreements as well, rather that your insurance company ...


1

Regardless of what state you are in, joint custody means both parents share expenses, responsibilities, and hardships. I understand you were not informed about the change of health plans since the last coverage was under the other parent employer insurance. In that case, I am assuming that he was making the full monthly premium to his/her employer without ...


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