Colorado state law guarantees a cluster of rights for the medical insurance consumer. These rights depend on what kind of insurance you have or are eligible for. Managed care (HMOs and PPOs), which is what most people have, has its own set of state regulations, but general rules govern all classes of care with one exception.
Requirements for Every Plan
The person insured (insuree) has a number of specific rights that the state protects. Typically, these take the form of obligations that the company must fulfill. The law requires insurance companies to pay any of their clients' claims promptly. The company must give a written explanation to its clients for any denial of coverage. In addition, the company has to allow you to appeal to the company and to an impartial third party if you are denied coverage. As for coverage, every insurance company must provide emergency room coverage. The company has to inform you of all the coverage options in your plan as well as provide you with a standardized comparison of its own plans against those of other companies. (See References, Health Insurance Laws.)
Exception--Self-Insured Company
Any company that pays its own employees' medical bills is called a "self-insured company." These companies are exempt from Colorado state regulations on medical insurance claims. But the self-insured do have to adhere to standard federal regulations.
Your Rights in Managed Care Plans
The most common types of managed care are HMOs (health management organizations) and PPOs (preferred provider organizations). Colorado law regulates both in the same ways. According to law, your doctor must inform you of all treatment options regardless of their expense. Your plan must provide emergency room care, even if you go to a hospital that is outside of your healthcare network. You also have the right to an adequate network of healthcare professionals. The insurance company has to notify you immediately if your primary care physician is no longer a part of your managed care network. If you are a woman, the company must provide direct access to an OBGYN practice. You also have the right to a complete review of your access plan, which describes the company's network, referral procedure, and its method for ensuring continuity of care.
Right of Appeal
Most appeals are against an insurance company's denial of care. The company usually claims that the care is not medically necessary. Colorado law requires the company to provide a two-stage process for the hearing of your appeal as well as an independent reviewer.
Pre-Existing Condition
Pre-existing conditions that will likely get you a polite decline from an insurance company are AIDS, diabetes, recent heart attack and cancer. If you have a pre-existing condition, group health plans can only decline you for up to six months, and individual plans only for up to 12 months.
If You Leave Your Job or Can't Get Coverage
If you leave your job, or are fired, you have the right to continue to use employer health insurance for 18 months. Your employer cannot legally prevent you from keeping your insurance. If you can't get coverage through an insurance company (usually because you're too sick), you can get it through ColoradoCovers, a government sponsored program, but you'll pay 30 percent more than for regular plans.
Tags: insurance company, company must, have right, must provide, also have
