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Health Insurance 101 - Understanding Health Insurance in Colorado

 

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Health insurance is a way for people and insurance companies to "share the risk" of medical costs. People — whether healthy or sick — pay premiums into a pool of money, administered by an insurance company, so that there is money to pay for services when someone in the pool of insured people needs medical attention.

Insurance pays for claims made when customers see a provider, need treatment or tests. If the insurance company collects more premium than they make in payments and other administrative costs, then they make a profit. If they pay out more in claims than they have collected, they show a loss.

Health Insurance Marketplace in Colorado pdf file

Overview of Health Insurance Regulation pdf file

Overview of Health Insurance Premiums in Colorado pdf file

 

Glossary of Health Insurance Policy Terms

The "Glossary and Definitions" section is provided so you can be familiar with some of the terms you may see in a health insurance policy. If you have questions, call the Division of Insurance for more information.

Glossary of General Insurance Terms and Definitions

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The cost of health care has risen dramatically over the past few decades. If you do not have medical insurance to help pay bills, a serious injury or illness can be financially devastating to you and your family. If you don’t have coverage you can be exposed to high health care bills; or, if you have too little or the wrong kind of coverage, you won’t have enough protection.

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Yes. It is completely up to the employer whether or not they will offer health insurance to employees , and they can change carriers and level of benefits at any time.

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You can apply for individual health coverage under the federal law Health Insurance Portability and Accountability Act (HIPAA). This type of policy is issued on a guaranteed issue basis if you meet the qualifying criteria. However, there is no limit on the maximum premium the insurance company can charge. Care for preexisting conditions may not be excluded from coverage.

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If your employer has more than 20 employees,you may be eligible for protection under the Consolidated Omnibus Budget Reconciliation Act (COBRA) law and entitled to a minimum of 18 months of continuation coverage. You can find out more about COBRA continuation of group health benefits from the Federal Department of Labor Office of Employee Benefits Security Administration website. If your employer has less than 20 employees, you may be eligible for State Continuation. More information is found here.

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Yes, a company has the right to deny coverage for almost any reason on a new application. However, once you are accepted for coverage, the company cannot cancel your policy except for nonpayment of premium.

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This is normally a physical or mental condition for which medical advice, diagnosis, care or treatment is recommended or received before the effective date of the policy.

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There are many programs available through the federal or state governments to assist with the high cost of health care and health insurance. You may contact the Colorado Department of Health Care Policy and Financingb to learn about your eligibility for Medicaid (for low-income and disabled persons), the Child Health Plan Plus (CHP+). Colorado’s high-risk pool is CoverColorado and provides coverage for individuals who are denied coverage in the individual market. You may also contact the federal U.S. Department of Health and Human Services for information about Medicare (including the new prescription drug program which provides many subsidies). In addition, the federal government provides tax credits for certain workers who have lost their jobs because of federal trade agreements or whose pension program has failed.

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An employer may choose to “self-insure” by paying out benefits from its own funds. Typically, an insurance company administers the program, but the liability for paying for the care of the employees rests on the employer. It is important for workers to understand that if their employer “self-insures,” state patient protections (such as access to internal and external appeals processes, assurance of certain benefits, and the right to have grievances heard by their State Insurance Department) do not apply. All federal protections (i.e., HIPAA and COBRA) do remain.

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If you have any questions about your policy, your rights and protections, or a potential agent or insurer, you can contact the Colorado Division of Insurance for information. You can also contact the Division for assistance if you have a grievance against a licensed health insurer.

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1560 Broadway, Suite 850, Denver, CO 80202 Email
(303) 894-7490 - Phone (800) 930-3745 - Toll Free (303) 894-7455 - Fax