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A CONSUMER'S GUIDE TO HEALTH INSURANCE from YOUR North Carolina Department of Insurance CONSUMER'SGUIDE A MESSAGE FROM YOUR INSURANCE COMMISSIONER Greetin gs, Whethe r or a ma you are enrollin naged c is made are plan g in a tradition a ,y al h informe vailable to Nor ou should know ealth insuranc d th Caro your rig e plan health in choices when lin s purchas a consumers t hts. This guide this guid urance plan is in oh e to be an impo g health insura elp you make your he in rt nce. Ch alth insu formative and ant decision. I oo rance o helpful hope yo sing a ptions. as you le u arn mor will find e about If you h av answere e any question d s insuran by this guide, about health in ce spec your De s North C ialists av aila partmen urance that are ar to no www.nc olina) at 1-800 ble to help you f Insurance ha t doi.com -546-56 . Call us s . 64, or v isit us o toll free (within n the W eb at Sincere ly, Wayne Goodw Insuran in ce Com mission er TABLE OF CONTENTS INSURANCE CONSUMER'S GUIDE TO LIFE Glossary of Insurance Related Terms .............................................................................................. 1 Types of Policies ............................................................................................................................. 3 Individual Coverage Vs. Group Coverage ....................................................................................... 6 Mandated Benefits and Other Plan Requirements ........................................................................ 11 Standard Policy Provisions, Limitations and Exclusions.................................................................. 15 Shopping for Health Insurance ..................................................................................................... 18 Shopping Comparison Chart ........................................................................................................ 20 Claims ......................................................................................................................................... 21 Appeals, Grievances and Requests for External Review ................................................................. 22 Health Insurance Tips .................................................................................................................. 23 Frequently Asked Questions ......................................................................................................... 24 Consumer Services and Consumer Complaints ............................................................................. 25 Consumer Complaint Form .......................................................................................................... 26 IF YOU HAVE QUESTIONS... The Consumer Services Division of the Department of Insurance is here to help. 800-546-5664 Toll free 919-807-6750 Outside of North Carolina 919-715-0319 TDD (Telephone Device for Deaf Callers) 919-733-0085 Fax You can find additional information as well as a downloadable copy of our complaint form on the North Carolina Department of Insurance Web site at www.ncdoi.com. North Carolina Department of Insurance 430 North Salisbury Street 1201 Mail Service Center Raleigh, NC 27699-1201 www.ncdoi.com INSURANCE TERMS GLOSSARY Appeal An insurance company's review of its own non-certification decision, after you dispute that decision. This process is available any time a plan issues a non-certification decision. The appeal process is voluntary. Keep in mind that if your insurance company denies payment on a claim because the service is excluded from coverage, you do not have the right to appeal. Your certificate of coverage should clearly list what services are covered and not covered. Certificate of Creditable Coverage A document prepared by the prior health insurance company that discloses the beginning and ending dates of coverage. It is generally used to show a new health plan how much pre-existing condition limitation credit a new enrollee has earned. Drug Formulary A list of prescription medications that have been approved for use by the health plan. An open formulary allows coverage for non-formulary medications. A closed formulary limits coverage to those drugs in the formulary. Emergency Care Every insurance company shall provide coverage for emergency services to the extent necessary to screen and stabilize the person covered under the plan and shall not require prior authorization of the services if a prudent layperson acting reasonably would have believed that an emergency medical condition existed. Payment of claims for emergency services shall be based on the retrospective review of the presenting history and symptoms of the covered person. Evidence of Insurability Proof that an applicant is an acceptable risk to the insurance company. Exclusions (Limitations) Provisions in an insurance policy that describe non-covered treatments and services or coverage limitations. Experimental/Investigational Until such time a treatment meets generally accepted standards of medical care in the community, it may be considered experimental or investigational. Grievance In addition to noncertification appeals, your rights under North Carolina law extend to other complaints against your health plan. Such complaints, called "grievances," can relate to any plan decision, policy or action related to the availability, delivery or quality of health care services; claims payment or handling; reimbursement for services or the contractual relationship between you and the plan. Insolvency The inability of a company to meet financial obligations or debts. 1 GLOSSARY Insured The person on whose life an insurance policy is written. Medically Necessary Services or Supplies Those covered services or supplies that are: Provided for the diagnosis, treatment, cure or relief of a health condition, illness, injury or disease and not for experimental, investigational or cosmetic purposes. Necessary for and appropriate to the diagnosis, treatment, cure or relief of a health condition, illness, injury, disease or its symptoms. Within generally accepted standards of medical care in the community. Not solely for the convenience of the insured person, the person's family or the provider. Policyowner The person or party who owns an insurance policy. The policyowner is often the insured person, but could be someone different. The policyowner is the only person who can make changes to a policy. Primary Care Physician (PCP) Doctors who provide general health care services and treatment. PCPs usually include family practitioners, general practitioners, pediatricians and internists. Provider A doctor, hospital, pharmacist or other health care professional or facility. Provider Network The doctors, hospitals, pharmacies and other health care professionals and facilities under contract with a health plan. Rider A modification or amendment to an insurance contract that may either expand, limit or exclude benefits. Third Party Administrator (TPA) A firm that provides administrative services to insurance carriers and/or employers. Underwriter A person employed by an insurance company who reviews applications for insurance and decides if the applicant is an acceptable risk. GLOSSARY 2 HEALTH INSURANCE POLICY TYPES You should consider several different options Some approaches used by managed care plans when shopping for a health insurance plan. This include: guide can help you choose the type of plan that Re quiring or encouraging members to best fits your needs. use a contracted network of doctors, hospitals and other health care providers. This enables plans to negotiate discounts MAjOR MEDICAl HEAlTH INSURANCE on behalf of members, thus keeping The two basic types of major medical (or costs down. Members' out-of-pocket comprehensive) health insurance plans are expenses are generally higher for care "traditional" plans and "managed care" plans. received outside of the plan network. Many people are covered under major medical Some HMO plans will not cover services plans, either through an employer group or by received outside of the network (except purchasing individual policies. for emergency services), while HMO Point of Service plans and PPO benefit plans Traditional Health Insurance cover some or all of the cost for services A traditional plan (also known as an "indemnity" received outside of the network. or "fee for service" plan) is designed to cover R eviewing medical treatments and a broad range of medical expenses such as services before agreeing to pay. This hospitalization, doctor visits, surgery, diagnostic process, known as Utilization Review, tests and prescription drugs. Most major medical determines whether the treatment or policies require policyholders to satisfy out-of- service is medically appropriate for your pocket deductibles each plan year, and (after health condition. If the Utilization Review deductibles are met) to pay a portion of the process finds that the services you have cost ("co-insurance") for covered services. A requested are not medically necessary traditional plan will allow patients to use a for your condition, then the plan will not doctor or hospital of their choice. The plan will pay for those services. More information pay claims based on charges that your provider about Utilization Review is on page 4. has agreed to in advance, or based on Usual, Li miting visits to specialists. Some Customary and Reasonable (UCR) charges that managed care plans may require members represent an average charge for the service to see their primary care physician provided, in your local area. Many traditional (PCP) before seeing a specialist. Because plans limit the total amount of benefits that can charges for specialist's services are be paid out during the policyholder's lifetime typically higher than for that of a PCP, this is a method of reducing unnecessary visits Managed Health Care Plans to expensive specialists. If a referral to a HMO, HMO Point of Service, and PPO benefit specialist is needed, the PCP can usually plans are the three most common types of assist with the arrangements; however, managed care plans. The term "managed care" it is the member's responsibility to verify refers to health plans that attempt to manage with the plan that the referral has been both the cost and quality of health care services approved. for their members. These plans involve certain processes and requirements that are different Health Maintenance Organizations (HMO) from those found in traditional health plans. HMOs are organizations that provide or These requirements are designed to encourage arrange for the delivery of health care services patients to seek the most appropriate health to their members in exchange for monthly care in the most cost effective setting possible. premiums. Covered services typically include 3 hospitalization, surgery, routine doctor to determine whether requested medical visits, diagnostic tests and prescription drug services are "medically necessary." Only treatment. As with other managed care plans, medically necessary services are covered HMO members usually pay a copayment under the plan. A plan's UR program must when they visit a health care provider. HMOs be administered by qualified health care in North Carolina use networks of contracted professionals, under the direction of a medical doctors, hospitals and other providers to doctor who is licensed in North Carolina. keep costs low. One benefit of this is that the insured person will minimize out-of-pocket A health insurance plan that uses Utilization costs by using a network provider. Review must: Traditional HMO Plans — HMO Routinely evaluate the effectiveness and members are generally required to seek efficiency of its UR program. health care treatment at designated Coordinate the UR program with its hospitals, physicians, HMO facilities other medical management activities and other in-network providers, except including quality assurance, credential- in the case of emergency. Some HMO ing, provider contracting, data report- plans require PCP referrals in order ing, grievance procedures, customer to see a specialist, and all have UR satisfaction and risk management. programs that review the medical Provide a toll-free number or a necessity of at least some requested collect call number, so that members health care services. can contact staff to receive prior HMO "Point of Service" (POS) approval (known as pre-certification) of Plans — POS plans are a more flexible services when required. type of HMO plan. POS members may choose to see out-of-network Limit requests for information to only providers for covered services, but at a information necessary to certify the higher out-of-pocket cost. Such plans admission, procedure or treatment, may cover certain services only when length of stay and frequency and received from in-network providers. duration of health care services. Sometimes, POS plan members must Notify members (and their providers) of choose a primary care physician and the decision whether or not to obtain referrals to specialists from certify services within three business their PCP. Other POS plans are "open days of receiving all information regard- access," meaning that no PCP referral is ing a request for services. required to see a specialist. When an insurance company denies a request, it must: Preferred Provider Organization (PPO) Benefit Plans — Issue a written noncertification PPO Benefit Plans are offered by insurance decision that includes all of the companies rather than HMOs. In many ways, reasons for the denial and a these plans resemble HMO Point of Service reference to the medical criteria plans; insureds may select from a network used to deny the request; of contracted physicians, hospitals and other — Inform the member on how to TYPES OF POLICIES health care providers, or use an out-of- request a copy of the medical network provider and be required to pay a criteria; and higher share of the cost. PPO plan members — Advise the member of the right to may generally see specialists without any prior appeal the decision and explain how referral or authorization. to file an appeal. Utilization Review (UR) Programs Have written procedures to address Most health insurance plans, even traditional the failure or inability of a provider or ones, make use of UR programs, which covered person to provide all necessary use established medical review criteria information for review. 4 TYPES OF POLICIES SUpplEMENTAl HEAlTH a different combination of benefits. For INSURANCE information and counseling on Medicare Supplement policies, contact the Seniors' Supplemental health insurance provides Health Insurance Information Program (SHIIP) limited coverage and benefits for specific at 1-800-443-9354 or visit www.ncshiip.com. health care conditions and expenses. Supplemental policies should not be used as a Specified Accident substitute for comprehensive health insurance Specified accident plans provide limited coverage. Following are some examples of benefits for covered accidents. Loss of limb or supplemental policies. sight in one or both eyes may also be covered. Cancer Cancer policies provide limited benefits lONG TERM CARE when the insured person is diagnosed with Long Term Care policies generally provide cancer (as defined in the policy contract). benefits for skilled and intermediate nursing Most policies contain a schedule of benefits home care. Benefits for personal (custodial) describing the amount of payments for care may also be provided for care received covered cancer treatments. Benefits under in approved facilities. These policies usually these types of insurance plans are normally pay a fixed amount per day while the insured paid directly to the insured person. person is in a nursing home. Most policies Dental contain waiting periods, during which no Dental insurance provides benefits for care benefits are paid. Some policies also cover and treatment of the teeth and gums. Benefits alternative types of care such as home health vary from policy to policy, as some may cover care or adult day care. Some even cover 100 percent of preventative care (such as home modification expenses. Normally, semi-annual check-ups, fluoride treatments, these policies cover care received in facilities etc.) while others may only cover a portion that are licensed by the state, participate of preventative care. Typically, dental in Medicaid and Medicare, and meet the insurance plans provide limited benefits for policy's definition of skilled, intermediate or preventative, basic, major and orthodontic custodial care. Information and counseling on services. There is normally an annual benefit long term care insurance is also available from maximum for covered services. Additionally, the Department of Insurance's Seniors' Health benefits for orthodontic procedures such as Insurance Information Program (SHIIP), at braces, retainers, etc. are usually very limited 1-800-443-9354. and have a lifetime benefit maximum. Hospital Indemnity Hospital indemnity policies provide benefits, usually a specified dollar amount, for each day of hospital confinement. Medicare Supplement The federal Medicare program covers most (but not all) medical expenses for people age 65 and older, and for individuals under age 65 receiving Social Security disability benefits. A Medicare Supplement policy may be purchased to help pay for deductibles, copayments and other expenses not covered by the Medicare program. By law, only 12 types (A through L) of Medicare Supplement policies may be sold, each of which offers 5 COMPARISONS INDIVIDUAL COVERAGE VS. GROUP COVERAGE Health insurance coverage is offered either it offers each affected individual the option through an individual policy or group to purchase any other individual health coverage. Under an individual policy, the insurance policy that it offers. This feature is policyholder is the insured person. Under known as "guaranteed renewability." Please a group policy, the policyholder may be an note that a company may decide to terminate employer, association, trustee, etc., while the all of its individual health insurance policies insureds are the members of that employer or with proper advance notice. other organization. Under group policies, the group (policyholder) generally has the right to continue, terminate or request changes to the GROUp HEAlTH INSURANCE group plan which, in turn, affects the coverage Many employers offer group health insurance of all individuals insured under the group. to their employees as an employment benefit. Under an individual policy contract, those Some employers offer only one plan while rights rest with the insured individual. others offer a choice of plans. No employer is required to offer health insurance; however, if this benefit is offered, it must be offered to INDIvIDUAl HEAlTH INSURANCE all eligible employees (eligibility requirements An individual health insurance policy is a usually include permanent status and working contract between you and the insurance 30 hours or more per week). company. You are the policyholder and a party to the insurance contract. An individual Under group coverage, a master group policy health insurance policy may cover one is issued to the group policyholder (the person or several family members. Typically, employer), and covered participants receive a individuals purchase this type of coverage certificate or handbook that summarizes the when they are not employed, or when they benefits and provisions outlined in the master are employed but do not have access to group group contract. Also, many group policies coverage. Also, individual health policies may provide the option of covering dependent be used to supplement Medicare. family members. Employers may require eligible employees to satisfy a waiting period Although individual coverage is often more of up to 90 days prior to being added to the expensive than similar coverage under a plan. Under employer group health insurance group policy, it can be an important means plans, the employer is the policyholder and of ensuring that a person has the health the employee is a plan participant. As the insurance coverage he needs, whether for policyholder, the employer does not need a long time or for a short period between the consent of plan participants to change jobs. Most people applying for an individual insurance companies, make changes to policy are subject to being underwritten by the plan, cancel the policy or agree to new the insurance company. This means that premiums or benefits. However, North the insurance company may review the Carolina law requires employers to provide individual's health history, and refuse or 45 days notice to their employees when they limit coverage based on that history (this plan to cease offering health insurance. No may not apply if you are a HIPAA-eligible company may cancel or refuse to renew individual. Read more about HIPPA on page coverage for individual eligible participants if 8). However, once an individual is covered, it continues to cover the rest of the group. an insurance company may not terminate or refuse to renew an individual policy unless 6 INDIVIDUAL COVERAGE VS. GROUP COVERAGE Small Groups Multiple Employer Welfare Arrangements Small groups are those employers with one (MEWAs) to 50 employees, including self-employed MEWAs provide coverage to employees individuals. of multiple employers in the same line of business. Rather than purchasing coverage Large Groups from an insurance company, a group of similar In North Carolina, large employer groups are employers may jointly establish a self-insured those with more than 50 eligible employees. (self-funded) health benefit plan by pooling When an employer applies for health funds, and then using the pooled funds to pay insurance, the insurance company may fully members' health care expenses. The North "underwrite" that group by requesting health Carolina Department of Insurance licenses information and deciding whether or not and regulates these "Multiple Employer to offer coverage. The group of employees Welfare Arrangements" as it does insurance must either be accepted or declined as a companies. However, the North Carolina Life whole — no one employee can be singled and Health Insurance Guaranty Association out. Once coverage is issued, large employer does not cover MEWA insolvencies; if a self- groups have guaranteed renewal rights. In insured MEWA runs out of money to pay addition, large group premium rates usually claims, its participating employers may be are developed using each group's past claims held responsible for those unpaid claims. history. Small Employer Group Health Coverage Reform Act N North Carolina's Small Employer Group Health Coverage Reform Act was enacted in 1992. The purpose of the Act is to promote the availability of accident and health insurance to small employers, eliminate abusive rating and underwriting practices, and improve fairness in the health insurance marketplace. All insurance companies who market or offer small group health insurance in North Carolina must offer all their plans to small employers who have one to 50 employees, provided that the employees reside within the insurance company 's service area. Self-employed individuals (as defined by the IRS) do not have guaranteed access to all plans, but they must be offered two standardized plans established by state law (known as the Standard and Basic health plans) regardless of their health status. North Carolina General Statutes define a "small employer" as any individual actively engaged in business that, on at least 50 percent of its working days during the preceding calendar year employed no more than 50 eligible employees, the majority of whom are employed within this state, and is not formed primarily for purposes of buying health insurance and in which a bona fide employer/employee relationship exists. Insurance companies have the right to verify whether small employers and self-employed individuals applying for coverage meet the above stated definitions. Insurance companies will most likely request tax and business documents during the application process and may refuse to issue coverage if proper proof is not provided. Additionally, those documents may be requested periodically after coverage is issued to verify ongoing eligibility. No company may single out a small group for termination or non-renewal if it will continue to serve other small groups in the same geographic area. The Small Employer Group Health Coverage Reform Act also establishes limits on how much insurance companies can vary premiums from one small employer to another. 7 WHAT HAppENS If I lOSE My or visit the U.S. Department of Labor's Web EMplOyER GROUp COvERAGE? site at www.dol.gov. When leaving an employer, continued State Continuation coverage may be available through COBRA North Carolina's State Continuation laws continuation, or through State continuation. allow employees and dependents to continue coverage under the employer's group health COBRA (Consolidated Omnibus Budget plan after they terminate employment Reconciliation Act) or otherwise lose eligibility. Under State Federal COBRA Continuation law applies Continuation guidelines, employees who to employer groups covering 20 or more terminate employment for any reason, employees. This law generally allows eligible whose hours are reduced or who lose eligible individuals to continue under the employer's employee status may continue their basic group policy for up to 18 months, but the health insurance coverage for up to 18 individual is responsible for paying the months. Upon termination or loss of eligible premiums. In some cases, the coverage can status, dependents covered by the policy continue for longer than 18 months. COBRA will also be able to continue coverage for 18 continuation law applies to both insured months. Unlike COBRA, State Continuation and self-funded plans; however, it does not laws do not provide for extensions of coverage apply to church plans, plans covering less beyond 18 months. In order to obtain more than 20 employees or plans covering federal information about State Continuation contact employees. Detailed information on your the North Carolina Department of Insurance rights under the federal COBRA laws can be toll free at 1-800-546-5664. A "Consumer's obtained from the U.S. Department of Labor's Guide to State Continuation" is available on Employee Benefits Security Administration, the Internet at www.ncdoi.com. Atlanta Regional Office at (404) 302-3900. For a complete list of publications provided by Conversion Policies the EBSA, call their hotline at 1-866-444-3272 All insurance companies that sell group health insurance plans must offer an individual INDIVIDUAL COVERAGE VS. GROUP COVERAGE conversion policy to individuals who lose coverage under the group plan, without imposing exclusions of pre-existing conditions. Conversion policies may cost substantially more than your previous group coverage. Some people may qualify as HIPAA (Health Insurance Portability and Accountability Act) eligible individuals and also be eligible for coverage under individual conversion policies. If you find yourself having both of these options, you should carefully compare the premiums and benefits and choose the plan that best meets your needs. HIPPA "Guaranteed Issue" Individual Health Insurance All private insurance companies that sell individual health insurance must offer a choice of at least two "guaranteed issue" plans for qualified HIPAA-eligible individuals. Those two plans must contain benefits that are similar to those offered under the insurance company's other plans. Companies that choose not to designate two plans for 8 INDIVIDUAL COVERAGE VS. GROUP COVERAGE Fully Insured Vs. Self-Funded Group Health Plans Fully Insured Fully insured group health insurance policies are offered by licensed insurance companies. The insurance company collects premiums and uses the money collected to pay claims. These types of policies are regulated by the North Carolina Department of Insurance, and are protected by the Life and Health Guaranty Association in the event that a licensed insurance company becomes financially insolvent. If this occurs, the Association provides up to $300,000 per person to cover unpaid claims. Self-Funded or Self-Insured Some employers and labor unions provide group health benefits for their employees or members through what is called a self-funded health plan. In a self-funded plan, the employer or group collects premiums itself and uses those funds to pay for claims. While an insurance company or other company may be responsible for administering the plan (provider network, claims processing , customer service, etc.), the employer retains responsibility for making sure that there are enough funds to pay claims. Self-funded health plans do not involve a health insurance policy; therefore, they are not insurance plans, and are not subject to North Carolina insurance laws or the North Carolina Department of Insurance's regulatory authority. In addition, the North Carolina Life and Health Insurance Guaranty Association does not cover self-insured plans in the event of plan insolvency. Single employer and union sponsored self-funded health plans are regulated by the U.S. Department of Labor's Employee Benefits Security Administration, under the guidelines of the Employees' Retirement Income Security Act (ERISA) of 1974. As noted earlier, self-insured MEWAs (which cover multiple employers) are licensed and regulated by the North Carolina Department of Insurance, but are not covered under the Guaranty Association. HIPAA-eligible individuals must offer all of You must have used up any COBRA or their individual insurance policies. However, State Continuation coverage for which there are no restrictions on the rates that you were eligible. insurance companies can charge HIPAA- You must not be currently eligible for eligible individuals for these plans, as long coverage under Medicare, Medicaid or as there is an actuarial basis for the rates. another group health plan. This means that the policies HIPAA-eligible You must not presently have health persons are entitled to buy tend to be rather insurance. (If, however, you know your expensive. To qualify as a "HIPAA-eligible group coverage is about to end, you individual," you must meet all of the following can apply as a HIPAA eligible individual requirements: for coverage to go into effect when your You must have had at least 18 months group coverage ends.) of continuous "creditable coverage," of You must apply for health insurance which at least the last day must have as a HIPAA eligible individual no later been under an employer group health than 63 days after losing your group plan. coverage. 9 For more information on this topic, see "Your HIPAA Rights and Guide to Individual Health Insurance" on the Department of Insurance's Web site, www.ncdoi.com. Government Sponsored Health Insurance NC Health Choice for Children NC Health Choice for Children (the State of North Carolina Children's Health Insurance Program) is a program funded by the federal and North Carolina governments. NC Health Choice may be discontinued at any time if federal money is no longer available. A child (under the age of 19) who lives in North Carolina and has no health insurance may be eligible, depending on family income. County health departments and social service departments determine whether a child qualifies for coverage under NC Health Choice. In order to obtain more information about this program, contact the North regarding Medicaid eligibility, call the Office Carolina Division of Medical Assistance toll of Citizen Services CARE-LINE Information free at 1-800-367-2229. Information can also and Referral Service toll-free at 1-800-662- be found on the Internet at www.dhhs.state. 7030. For local calls or calls from outside of nc.us/dms/cpcont.htm. North Carolina, dial (919) 733-4261. The Office of Citizen Services has a dedicated Medicaid TTY line at 1-877-452-2514 or for local TTY Medicaid provides medical assistance to low- or TTY calls from outside of North Carolina, income families and individuals of all ages dial (919) 733-4851 for the deaf and hearing INDIVIDUAL COVERAGE VS. GROUP COVERAGE participating in cash assistance programs. impaired. Federal and state governments jointly finance Medicaid. All states, the District of Columbia Medicare and some U.S. territories have Medicaid Medicare is a federal health insurance programs. Medicaid programs are governed program for people age 65 years or older, by federal guidelines, but eligibility criteria people with certain disabilities, and people and covered services can vary from state with permanent kidney failure being treated to state. In North Carolina, each county with dialysis or a transplant. Medicare has determines eligibility. For individuals who two parts: Part A (hospital insurance) and Part qualify for both Medicaid and Medicare, B (medical insurance). For more information Medicaid pays Medicare cost-sharing amounts concerning Medicare and Medicare and fills in many gaps in Medicare's benefit supplements, contact the North Carolina package, especially in the area of long-term Department of Insurance's Seniors' Health care services and prescription drugs. In Insurance Information Program (SHIIP) toll- order to obtain more information about this free at 1-800-443-9354, or visit our Web site program, contact your county's Department at www.ncdoi.com. of Social Services (DSS). You may go to the DSS to apply or ask them to send you an application in the mail. Applications are also available at your county's health department. You may complete the application yourself and return it in person, or mail it to the DSS. If you cannot locate the phone number for your local DSS or if you have further questions 10 REQUIRED BY LAW BENEFITS North Carolina law requires insurance carriers estrogen-deficient and at clinical risk of to include certain benefits in major medical osteoporosis or low bone mass. health insurance policies that are offered in possessing radiographic osteopenia this state. Some of these benefits are: anywhere in the skeleton. Emergency Services receiving long-term glucocorticoid Every insurance company must cover (steroid) therapy. emergency services necessary to screen having primary hyperparathyroidism. and stabilize the insured person, if those being monitored to assess the response services meet the "prudent layperson" to or efficacy of commonly accepted standard (meaning that a layperson would osteoporosis drug therapies. have reasonably believed that an emergency medical condition existed). A managed care having a history of low trauma fractures. plan cannot require prior authorization for having other conditions or on medical emergency services, or require that an in- therapies known to cause osteoporosis network hospital's emergency room be used. or low bone mass. Copayments and/or deductibles generally apply. Diabetes Treatment and Services Policies must cover medically appropriate and Minimum Hospital Stay Following Childbirth necessary diabetes treatment and services. Health benefit plans that provide maternity Outpatient self-management training and and childbirth benefits are required to cover educational services, equipment, supplies, both the mother and her newborn child for a medications and laboratory procedures used minimum of 48 hours of inpatient care after to treat diabetes must also be covered. normal childbirth, or for a minimum of 96 hours of inpatient care following a cesarean Mastectomy Length of Stay and section, as long as the physician determines Reconstructive Breast Surgery Following that inpatient care is appropriate. Unless Mastectomy the child is covered as a dependent under Insurance companies must allow the patient's a parent's plan, coverage for the newborn's physician and the patient to determine how care will end after the first 48 hours (or 96 long she will remain in the hospital following hours for a cesarean section). State law does a mastectomy. Coverage must be provided not require health insurance plans to offer for reconstructive breast surgery following maternity care. a mastectomy performed in the course of treating cancer or breast disease. Mammograms and Pap Smears Every policy must cover pap smears and low- Chemical Dependency dose screening mammography. All insurance companies offering group policies must offer benefits for the care and Bone Mass Measurement treatment of chemical dependency. Health benefit plans must cover scientifically proven and approved bone mass Contraceptives measurement for the diagnosis and evaluation Every insurance company providing a health of osteoporosis or low bone mass in certain benefit plan covering prescription drugs "qualified" individuals. To be a qualified or devices must also provide coverage for individual, the insured person must meet at prescription contraceptive drugs or devices. least one of the following characteristics: 11 considered to be in place at the moment of birth or placement, regardless of whether you provided your insurance company with advance notification of your new child. However, notifying the insurance company prior to or soon after birth or placement is a good idea in order to avoid delays in claim processing. If your policy will require additional premium, however, you must notify your plan prior to birth or placement or within 30 days of birth or placement, in order for the coverage to be in effect from the moment of birth or placement. Otherwise your plan may exclude or place a waiting period on coverage for pre- existing conditions, including birth defects. This includes outpatient contraceptive services Mentally Retarded or Physically if outpatient care is provided. Religion-based Handicapped Children employers may request an exemption. The age limitation for dependent children will not apply for a child who is, and continues to Newborn Hearing Screening be: All health insurance companies are required Incapable of self-sustaining employment to cover hearing screenings for newborn by reason of mental retardation or children, subject to the deductibles, physical handicap; and copayments and coinsurance that generally Chiefly dependent on the policyholder apply to other services covered by the plan. for support and maintenance. Clinical Trials Policy guidelines must be followed to properly All health insurance companies are required notify the insurance company of any request to cover medically necessary expenses for to continue coverage for qualified children. phase II, III and IV clinical trials that are not directly related to conducting the trial itself, Network Adequacy not provided by the parties conducting the Managed care (HMO and PPO) plans trial, and that would be covered if provided must maintain adequate provider networks outside of a clinical trial. To be covered, the that provide access to covered services trials must meet certain minimum medical within a reasonable distance, and without and scientific requirements. unreasonable delay. If a managed care plan's BENEFITS REQUIRED BY LAW network does not offer reasonable access to Adding Newborn Infants and Adopted or an appropriate provider, then the plan must Foster Children allow its member to receive needed care from Newborn children, newly adopted children out-of-network providers, without holding the and newly placed foster children who are member responsible for any more than the covered as dependents are considered to be standard in-network copayment, coinsurance covered from the moment of birth or moment or deductible. Managed care plans are of placement in a home, as long as the policy required to establish their own standards for was in effect at that time. When coverage network accessibility. becomes effective in this manner, exclusions and waiting periods for pre-existing conditions may not be applied. If your existing policy automatically covers your new child with no additional premium, then the policy is 12 BENEFITS REQUIRED BY LAW Exceptions to Drug Management Standing Referrals to Specialists Requirements Managed care plans that require members All health plans that use a closed prescription to obtain a referral from their primary care drug formulary must cover drugs that physician (PCP) before seeing a specialist must are not on the formulary, under certain allow the PCP to issue a standing referral for circumstances: up to 12 months if the patient has a serious A plan member's physician notifies the or chronic condition that is degenerative, insurance company that the formulary disabling or life-threatening and ongoing drug has been used to treat the patient specialty care is necessary. for the condition in question; and Transitional Coverage when a Provider The formulary drug was either Leaves the Network (Continuity of Care) ineffective in treating the condition, Managed care plans must allow members to harmful to the patient, or is reasonably continue receiving coverage for treatment expected to be harmful to the patient from providers who leave the plan's network, and therefore, the non-formulary drug in order to ensure continuity of care while is necessary to treat the condition. the member changes providers. This coverage Restricted access drugs (formulary drugs that is dependent upon specific conditions being are covered only with insurance company's met, including: prior approval, or only after other specified formulary drugs have been tried without The member — success) must also be covered on an — has a serious acute condition that exception basis, without prior approval or first requires treatment to avoid death or having to try other formulary drugs, when: permanent harm, at the time he/she A plan member's physician certifies to was notified that the provider was the insurance company that the other leaving the network (up to 90 days formulary drug(s) has been used to of transitional coverage is provided); treat the patient for the same condition or, previously; and — has a chronic condition that is The drug(s) was either ineffective or life threatening, degenerative or harmful to the patient and is expected disabling and requires treatment to be harmful if used again. over a prolonged period of time, at Related Publications Available from NCDOI A Consumer Guide to Cancer Insurance A Consumer Guide to External Review Employees Guide to HIPAA Rights Regarding Health Insurance Employers Guide to HIPAA Rights Regarding Health Insurance Guide to Appeals and Grievances Health Insurance Premium Assistance Managed Care in North Carolina (Annual Status Report) Managed Care in North Carolina (Annual HEDIS Supplement) What Happens To My Coverage If My Job Status Changes (state Continuation) Your HIPAA Rights and Guide to Individual Health Insurance Getting Off to a Good Start with Medicare Medicare Changes and Options Medicare + Choice Comparison Guide Medicare Supplement Comparison Guide Guide to Long-Term Care Insurance 13 the time they were notified that the insurance company of his/her desire provider was leaving the network to take advantage of this coverage. (up to 90 days of transitional The same rights to continuity of care coverage is provided); or, described above apply when your — is in at least the second trimester employer changes from one health plan of pregnancy, at the time he/she to another, and your provider does not was notified that the provider was participate in the new plan's network. leaving the network (transitional Continuity of care requirements do coverage is provided through not apply when you choose to change delivery and up to 60 days of plans. postpartum care); or, Specialists as Primary Care Provider — is scheduled for surgery, organ Managed care plans that require the use of transplantation or other inpatient a PCP must allow members with serious or care prior to being notified of the chronic conditions that are degenerative, provider's termination (transition disabling or life-threatening and require coverage is provided through the ongoing specialty care to select a specialist completion of the procedure or stay . to act as their PCP This is subject to the and up to 90 days of post-discharge insurance company agreeing that the specialist care related to the hospital stay); or, is capable of coordinating the patient's care, — is terminally ill and not expected to and the specialist agreeing to abide by the live longer than six months, at the insurance company's procedures for PCPs. time that the provider will actually leave the network (transition Direct Access to Specialists coverage is provided for the Managed care plans are required to allow remainder of the member's life). female members 13 years old or older to have direct access to an OB/GYN for OB/ The provider leaving the network must GYN services, without a referral from a PCP . agree to continue treating the member, Managed care plans are required to allow accept the plan's payment rates, and all members who are under the age of 18 to comply with other plan requirements. select a network pediatrician as their PCP. The member must, within 45 days of being notified that their provider will be leaving the network, notify the Disclosure NNorth Carolina law requires all insurance companies to clearly and truthfully BENEFITS REQUIRED BY LAW disclose the following information in their marketing materials and all health insurance policies: A clear description of health insurance benefits. A complete list of items and services that the health care plan does not cover (exclusions and limitations). An explanation of how the insurance company will calculate its own claim cost (share of a claim) and your share, including an example of how they make that calculation. Length of time you must wait in order to receive benefits if the policy contains preexisting health conditions limitations. Renewal terms and provisions. Premium rate terms and provisions. 14 STANDARD POLICY PROVISIONS LIMITATIONS AND EXCLUSIONS No matter what kind of health insurance plan annual or a $250 per illness deductible. you have, be sure to review and study your Choosing a higher deductible may help lower policy. It is important for you to understand your premium. your rights, obligations, covered services and excluded services. If at any time you do not understand your policy or have questions, you COINSURANCE can contact the Department of Insurance at Coinsurance is the amount (usually states 1-800-546-5664 from anywhere within North as a percentage) that must be paid by the Carolina. Our specialists are here to help you. insured person for covered services, after the deductible has been met. For example, if a Some common provisions, limitations and policy pays 80 percent of covered charges, exclusions in health insurance policies are: then the insured person's coinsurance amount will be the remaining 20 percent of covered fREE-lOOk pERIOD charges. When applying for an individual health Note: When covering services rendered insurance policy, you may return the policy to by out-of-network providers, some plans the company within the free-look period and base their own payment and the member's receive a complete refund of all premiums coinsurance on "allowed" amounts. If the paid, if you are not satisfied for any reason. out-of-network provider's total charges are The minimum free look period is 10 days, greater than the plan's allowed amount, the beginning with the date of policy delivery. member may be billed by the provider for Returning the policy during the free look the remaining balance. Members who receive period voids all benefits from policy inception. care from in-network providers should never be subject to balance billing, as long as the services were covered and (if necessary) pREMIUM pAyMENT GRACE pERIOD properly authorized by the plan. Check your Health insurance companies must allow member handbook and contact your plan, if policyholders a grace period after each you have any questions about your out-of- premium due date. During the grace period, pocket liability for health care services. the policy remains in full force and effect. However, if a premium is not paid prior to COpAyMENT the expiration of the grace period, the policy will lapse. Benefits typically terminate on the This is a fixed dollar amount (such as $10, last day of the premium period for which $20, etc.) that insured persons are required premiums have been paid. The industry norm to pay directly to the provider, for covered for premium grace periods is 31 days. In some services. instances, though, the grace period might be less than 31 days. COORDINATION Of bENEfITS DEDUCTIblE The Coordination of Benefits provision applies when a member is covered by two The deductible is an initial out-of-pocket health plans. It spells out how the charges amount that members must pay for covered for covered services will be paid by the two services, before the plan begins to pay. For plans, so that total benefits do not exceed example, a health plan may require a $250 total charges. 15 pRE-ExISTING CONDITIONS Any coverage under a group plan (including COBRA or State Continuation), individual A health plan may refuse to pay for treatment health insurance policy, Medicare or Medicaid of health conditions that existed prior to your or North Carolina's Health Choice program enrollment in a health plan. For group health or comparable children's health plan offered plans, both federal and North Carolina laws by another state is considered "creditable place time limits on the exclusion period for coverage." As proof of coverage, employers pre-existing conditions. Under federal and and/or insurance companies are required to North Carolina law, a pre-existing condition provide a "certificate of creditable coverage" is one for which you received medical to insured persons when coverage ends. That advice or treatment within six months prior certificate is used to show the person's new to enrolling in the plan. The maximum pre- health plan the amount of pre-existing credit existing condition exclusion period for timely to which the person is entitled. enrollees (individuals who enrolled in the group plan at the first opportunity to do If your coverage with a plan ends for any so) is 12 months. An 18 month pre-existing reason, it is very important that you save this condition exclusion period may be imposed certificate of creditable coverage. Benefits on late enrollees (anyone who did not enroll for pre-existing medical conditions cannot when they were first eligible to do so). If be denied under any plan's pre-existing you have an individual major medical plan, condition limitation provision if the person has a pre-existing condition may be defined as had creditable coverage for at least 12 months a health condition for which you received without a break (or lapse) in coverage of more medical advice, diagnosis, care or treatment than 63 days. within 12 months immediately prior to the effective date of your plan. The maximum pre-existing conditions waiting period for INCONTESTAblE pROvISION individual coverage is 12 months. Generally, pre-existing condition waiting periods under Generally, insurance companies can contest both group and individual plans can be the validity of a policy within the first two reduced by the length of time that coverage years after the policy is issued (or reinstated), was maintained under prior health insurance if they suspect that information on an plans, provided that there was not a lapse of application was misstated or misrepresented, 63 days or more between plans. and that this information affected the insurance company's decision to issue the policy. pORTAbIlITy STANDARD POLICY PROVISIONS For many years, people have been concerned lIfETIME lIMITS about the effect that changing jobs can have on health insurance coverage. Previously, Most health insurance policies limit the total medical conditions covered under a prior plan dollar amount that the policy will pay over the were often not covered under the subsequent course of the insured person's lifetime (such as plan. The Health Insurance Portability $1 million). Once this limit has been reached, and Accountability Act (HIPAA), though, policy benefits will cease. guarantees that insured persons get "credit" for the time covered under the previous plan, ANNUAl lIMITS provided that the period between plans is no more than 63 days. Specifically, insurance Annual limits cap the total dollar amount of companies must reduce any pre-existing benefits payable during the course of the condition limitation periods by the amount policy year, and usually pertain to a specific of time that the insured person was covered type of benefit or covered service. under prior creditable coverage. 16 STANDARD POLICY PROVISIONS OUT-Of-pOCkET MAxIMUMS Many policies limit the total coinsurance amount you must pay each year. Once you reach the coinsurance limit specified in your policy, the insurance company will pay 100 percent of covered charges for the remainder of the year. USUAl, CUSTOMARy AND REASONAblE (UCR) CHARGES Insurance companies may (for some covered services) base their reimbursement amounts on Usual, Customary and Reasonable (UCR) charges, if permitted under the policy contract. This is typically the case for treatment received from out-of-network providers. Generally, UCR determinations are based upon average costs, in your local area, for the health care services in question. COvERAGE ExClUSIONS Although you may purchase a plan that covers most medical, hospital, surgical and prescription drug expenses, no health plan will cover every conceivable medical expense you may incur. Examples of common exclusions include: Vision care (eye exams, glasses, contacts, etc.) Hearing aids Dental care Cosmetic surgery Experimental treatments Specific Treatments (e.g., sterilization, acupuncture, etc.) NORTH CAROlINA lIfE AND HEAlTH INSURANCE GUARANTy ASSOCIATION To protect North Carolina insureds against company insolvencies, the North Carolina General Assembly created the North Carolina Life and Health Guaranty Association. The Guaranty Association provides up to $300,000 of benefits per person (for guaranteed policy benefits) on covered policies in the unlikely event of insurer insolvency. The association is funded by insurers licensed to do business in North Carolina. 17 SHOPPING INSURANCE FOR HEALTH Most people enroll in their health plan company was licensed in North Carolina, as through an employer. When this is the case, well as general information on the company's your employer selects the insurance company complaint history. Additional information or companies and decides which plan or plans is available to consumers through a variety will be available to you. Many employers of other sources, including the Internet, that offer health insurance pay at least some consumer magazines and publications, public of the premium for the employee, and some libraries, consumer groups, etc. An insurance employers also pay part of the premium to company's financial strength is very important. cover dependents. Health benefits are a large Independent rating organizations such as expense for employers, so employers must A.M. Best, Standard & Poor's, and Moody's choose between different types of plans and Investors Service publish financial ratings. benefit levels. If your employer offers a choice Consider checking at least some of these of plans, you will want to want to choose resources to evaluate a company's strength; your plan with care. Likewise, if you decide they can be found in most public libraries, by to purchase individual health insurance, it is asking your agent, or on the Web. important to select a product that meets your specific health care needs. CHOOSING A plAN Aside from the type of plan and benefits WHERE TO SHOp covered, there are some other factors you As with any major purchase, it is may need to consider when choosing a health recommended that you shop around to make plan. The following items should be carefully sure you get the best value for your money. considered. Many insurance companies and agents advertise in the yellow pages, newspapers, Premiums television and/or radio. In addition, the The premium is the amount paid for the insurance policy. Health insurance premiums Internet can be a valuable tool for researching can vary greatly, depending on applicant age specific companies and products, and in some and health history, the type of plan, the range cases obtaining preliminary quotes. Insurance of services covered by the plan, the plan agents must be licensed to sell insurance in deductible, lifetime maximum, and other North Carolina. Choose one with whom you factors. feel comfortable and who will answer your questions. To verify that an agent is licensed, Other Out-of-Pocket Expenses contact the North Carolina Department of In addition to monthly premium payments, Insurance, Agent Services Division at (919) most health plans require you to pay a portion 807-6800. Similarly, insurance companies of covered expenses, such as deductibles, must be licensed to conduct business in North coinsurance, copayments and excess charges Carolina. To verify that a company is properly when a provider's charges are higher than the licensed, you may contact the Consumer plan's allowed amount. The out-of-pocket Services Division at (919) 807-6750 or 1-800- expenses for which you will be responsible 546-5664. should be considered along with the premiums when shopping for a plan. Seek Unbiased Information The North Carolina Department of Insurance Selecting the Right Managed Care Plan does not rate or recommend insurance If you have the option of choosing between companies, but can provide the date a two or more plans, you should carefully 18 SHOPPING FOR HEALTH INSURANCE compare the differences. Aside from the Are there any limits on the number of obvious differences in covered benefits, times you may receive a service? benefit levels (how much the plan pays) What are the restrictions on the use of and premiums, you should also consider providers or services under the plan? factors such as each plan's provider network, Does the health plan require you to see pre-authorization requirements, access to a provider in its network? specialist care, etc. Many health insurance companies place their provider directory on Are the network providers conveniently their company Website so you can check located? on whether your providers participate in an Is the doctor you want to see in the insurance company's network. network and accepting new patients? What do you have to do to see a In addition, before selecting a plan, review specialist? the plan summary carefully, call the plan for information, and (if possible) talk with How easy is it to get an appointment coworkers and friends about their experiences when you need one? with the plan you are about to select. Health Has the company had an unusually high plans are required by law to honor your number of consumer complaints? request for a copy of the policy or evidence When calling the insurance company, of coverage BEFORE you enroll. Information how long does it take to reach a real concerning coverage criteria for specific person? conditions, information on prescription drug formularies and coverage of experimental procedures is also available at your request. QUESTIONS TO ASk WHEN SHOppING fOR A plAN What services does the plan cover? What is not covered? Will the plan cover preventative care, immunizations, well-baby care, substance abuse, organ transplants, vision care, dental care, infertility treatment, durable medical equipment or chiropractic care? Will the plan pay for prescriptions? Does the plan provide mental health benefits? Will the plan pay for long-term physical therapy? Do rates increase as you age? How often can rates be changed? How much do you have to pay when you receive health care services? Are there any limits on how much you are personally required to pay for health care services you receive? 19 SHOPPING COMPARISON CHART Company Name Company Name Questions to Ask 1 How much is the deductible? $ $ 2 Do I have to pay a co-insurance amount? Yes No Yes No If so, how much? $ $ 3 Are there waiting periods before certain illnesses are Yes No Yes No covered? 4 Does the policy have an annual benefit maximum? Yes No Yes No If so, how much? $ $ 5 Does the policy have a lifetime benefit maximum? Yes No Yes No If so, how much? $ $ 6 What are the limits on: Daily hospital room and board $ $ Medical tests or other hospital expenses $ $ Amount paid for doctor's visits $ $ 7 What is not covered? 8 Will the policy pay for: Maternity care Yes No Yes No Prescriptions Yes No Yes No Immunizations Yes No Yes No Well baby care Yes No Yes No Vision care Yes No Yes No Dental care Yes No Yes No Infertility treatment Yes No Yes No Chiropractic care Yes No Yes No Additional questions for managed care comparisons. 9 How much is the co-payment? $ $ 10 Are my doctors in the network? Yes No Yes No 11 Do I need a referral to see a specialist? Yes No Yes No 12 Are non-emergency, out-of-network services covered? Yes No Yes No 13 Are network providers conveniently located? Yes No Yes No 14 Is the doctor I want to see accepting new patients? Yes No Yes No 15 Does the plan allow providers to balance bill me for the Yes No Yes No difference between allowed and actual changes? This is only an example. You may need to tailor a comparison chart of your own to address your individual needs. 20 FILING CLAIMS CLAIMS SUbMIT ClAIMS pROpERly requires additional information, it must specify what is needed. After receiving the additional Find out if you are responsible for filing information, the company has an additional your claims or if your provider will file them 30 days to take action on the claim. for you. If you are required to submit the claim, review the information to be sure it is complete and correct before forwarding it to ExplANATION Of bENEfITS (EOb) the insurance company. File it as soon as you receive the bill from the provider. Send it to The Explanation of Benefits (EOB) is a the correct address and keep a copy for your statement sent to you from the insurance records. company, explaining its claim determination and benefit calculation. Information provided on the EOB should be carefully analyzed in AllOW A REASONAblE TIME conjunction with your medical bills and policy contract. Any questions or discrepancies For many types of health insurance plans, should be promptly addressed with the the insurance company must take action on insurance company. a claim within 30 days after receipt. "Taking action" means the insurance company must pay, deny, or pend the claim for additional information. If the insurance company Before You Receive Health Care Services Plan Ahead R e a d y o ur policy or employee benefits booklet carefully to be sure w hat se r vices a re co vered. F ollow any m anag ed c ar e r ules, suc h as the u s e o f n etwork providers. Give correct insurance information to your p r o v i d e r. If you, your spouse or your covered dependents have health c a r e c o v erage under more than one group plan, you should review eac h e m p l o y e e benefit booklet to determine which policy is primary and w hi c h i s s eco n da ry. Pre-Certification M a n y p l ans require you to contact the insurance company for approval b e f o r e y ou check into the hospital, have elective surgery, visit speciali s t s o r h a v e expensive tests. The steps should be spelled out in your policy b e n e f i t s booklet. Pre-certification does not necessarily guarantee the p a y m e n t of your claims. However, if your plan pre-certifies a service, i t c an not l a t er den y co vera ge on the g r ounds that the ser v ice was not m e d i c a l l y necessary, unless the pre-certification was granted based on f a l s e i n f ormation from you or your provider. Please note: An insurance c o m p a n y cannot require pre-certification for emergency medical servic e s or t re at m en t . 21 APPEALS AND GRIEVANCES AND REQUESTS FOR EXTERNAL REVIEW ExTERNAl REvIEW Of HEAlTH plAN DENIAlS The North Carolina Department of Insurance Health Care Review Program (HCR) administers a free service called External Review, which provides another option for resolving certain coverage disputes between you and your insurance company. In North Carolina, external review is available when an insurance company denies coverage on the grounds that the requested service is not medically necessary (this is called a "non- certification" decision), or that the requested service is cosmetic or experimental for your specific medical condition. For your request to be accepted for external review, you must meet the Program's eligibility requirements. A request is made directly to the HCR Program and each case is reviewed AppEAlS AND GRIEvANCES for completeness and eligibility. If accepted If you are dissatisfied with a claims decision for external review, the case is assigned to an made by your health insurance company, you independent review organization (IRO) for a may have the right to challenge that decision clinical review and final decision. Additional through an appeal and/or grievance process. information about External Review can be A guide describing the appeal and grievance found on the Department's Web site at provisions in North Carolina law is available www.ncdoi.com, or by calling the HCR through the Department of Insurance by Program at 1-877-885-0231. calling 1-800-546-5664 or visiting www.ncdoi.com. Laws regulating appeals and grievances apply to all types of full service health plans, including traditional indemnity, HMO and PPO plans. Patients with certain health conditions may be eligible for an expedited (quicker) appeal process. Details concerning your plan's appeal and grievance procedures should be included in your employee handbook, certificate of coverage and insurance policy. 22 HEALTH INSURANCE TIPS BEFORE AND AFTER YOUR PURCHASE fOR All TypES Of HEAlTH A complete list of items and services INSURANCE: that the health care plan does not cover (exclusions and limitations). Make sure all claim forms are filled out An explanation of how the insurance promptly, completely and accurately. company will calculate its own claim READ YOUR POLICY and keep it in a safe cost (share of a claim) and your share, and secure place. including an example of how they make Ask questions. that calculation. Length of time you must wait in order fOR INDIvIDUAl INSURANCE: to receive benefits if the policy contains preexisting health conditions limitations. Shop around. Compare plans from more Renewal terms and provisions. than one company. Do not feel pressured Premium rate terms and provisions. to make a quick decision. Verify that the agent and company you choose to do business with are licensed in North Carolina. DO NOT PAY CASH. When you purchase a policy, make your check or money order payable to the insurance company, NOT THE AGENT. Be sure to get a receipt. Make sure you fully understand any policy you are considering and that you are comfortable with the company, agent and product. Do not sign an insurance application until you review it carefully to be sure all the answers are complete and accurate. Keep in mind that you have a minimum 10-day "free look" period. If you cancel during the free look period, the company must return your premium without penalty. DISClOSURE North Carolina law requires all insurance companies to clearly and truthfully disclose the following information in their marketing materials and all health insurance policies: A clear description of health insurance benefits. 23 FREQUENTLY ASKED QUESTIONS FAQ'S When I apply for insurance, what information will I be asked to provide? To determine your eligibility, companies generally ask for medical and personal information. Can an insurance company void my policy if I made a mistake in completing the application? Health insurance companies may void contracts within the first two years, if the applicant provides inaccurate or incomplete responses to the application questions, and if the company relied on those responses in deciding to issue the policy. Always verify that answers and information submitted on any application for insurance are complete and accurate. What are my rights to continue my health insurance if I lose my job? You may be eligible to continue your group health insurance for up to 18 months by means of COBRA or State Continuation. The employer and/or insurance company cannot require you to pay more than 102 percent of your full group premium rate. See page 8 for more details. What is association group health insurance coverage? Under an association group arrangement, the master group policy is typically issued to the association, and coverage is offered to the association's members. Generally, each individual applicant must meet the company's underwriting guidelines. Applicants who fail to qualify may be denied coverage or exclusionary riders may be attached to the policy. Am I guaranteed the right to purchase individual health insurance? No. Except under certain circumstances, insurance companies have the right to fully review your application and determine whether you are an acceptable risk. If not, your application may be declined. What is HIPAA (Health Insurance Portability and Accountability Act)? HIPAA affects individuals who change from one employer group plan to another, and to those individuals who lose their eligibility for group coverage. Two of the most important features of HIPAA are health plan "portability" and the availability of "guaranteed issue" individual health insurance. Information on page 8 will provide you with more details. Does the Department of Insurance set the rates and tell companies how much they can charge? No, the North Carolina Department of Insurance does not have the authority to set health insurance rates. However, carriers are required to justify their rates and demonstrate that they are actuarially sound and not unfairly discriminatory. I have a child who is going to be attending school outside my HMO's (or other managed care plan) service area. Will my child be covered? Children who live and attend school outside the HMO's service area are subject to the same requirements as all other persons covered by the plan. The child must return to the plan's service area in order to receive full benefits. However, the plan must cover emergency treatment outside of the service area. I am currently covered under my employer's HMO. I plan to leave my job and move to another state. Do I have any COBRA or North Carolina State Continuation rights? If you move out of the plan's service area, your coverage will most likely be terminated. I have an exclusion rider on my individual health policy. How long will it remain in effect? The rider will remain in effect for the length of time specified by the terms of the rider. If there is no time limitation specified, it will remain in effect for the duration of the policy unless the insurance company agrees to remove it. 24 SERVICES CONSUMERCOMPLAINTS AND The Consumer Services Division strives to WHAT WE CANNOT DO respond promptly, clearly and courteously to consumers' insurance-related questions and Act as your legal representative in or complaints., in an effort to help consumers out of court. understand their options and resolve their Intervene in a pending lawsuit, on your insurance problems. behalf. Consult with you if you are represented If you have a problem or concern with an by an attorney, unless we have your insurance company or agent, the North attorney's written permission. Carolina Department of Insurance stands ready to assist you. A consumer complaint Regarding a dispute between you and form is included in this brochure for your your insurance company, establish: convenience on page 26. — Who was negligent or at fault. — The value of a claim or the amount of money owed to you. WHAT WE CAN DO TO HElp — The facts surrounding the claim Forward a copy of your complaint to (that is, who is being truthful when your insurance company, and require there are differing accounts of what the company to provide a response/ happened). explanation. — The facts regarding any other Review the company's response for disagreement between you and compliance with applicable North another party. Carolina statutes, regulations, and Address plans or companies that are not policy requirements. subject to the insurance laws of North Require the company to take corrective Carolina, or that are governed by other action if we determine that the state agencies. company's position does not comply The North Carolina Department of with applicable requirements. Insurance pledges to seek fair and equitable Help you understand your insurance treatment of all parties in insurance policy. transactions. Recommend courses of action that you can take to resolve your problem, if we do not have the regulatory authority to resolve it ourselves. If your situation involves a health plan's noncertification decision (denial based on lack of medical necessity), refer you to the Department of Insurance's Health Care Review Program (HCR Program), for further guidance. 25 5,000 copies of this public document were printed at a cost of $##### or $### per unit. (Revised January 2009) North Carolina Department of Insurance Wayne Goodwin, Commissioner 1201 Mail Service Center Raleigh, NC 27699-1201 www.ncdoi.com
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subset: commoncrawl


text:
The Linux malware story comes around, again
Off the Beat: Bruce Byfield's Blog
Very few computer journalists or users understand that security means more than regular updates and virus-scans. As a result, every now and again, a scare makes the headlines. The latest scare is the Hand of Thief trojan described last week by RSA that is supposed to target Linux specifically.
These scares are predictable in their content and claims. One popular pronouncement is that Linux has only escaped its share of malware because of its relative unpopularity, and the latest scare is a sign that things are about to change. This prediction can be guaranteed to draw sniggers from Windows users, who are tired of the weaknesses of their operating system being constantly mentioned, and thirsting for payback. Often, it respawns jokes, like the title of Brian Fagioli's story on the trojan, "Linux gets hit by a trojan -- it's time to sudo apt-get scared!"Half-informed claims are exchanged on both sides, as well as the odd prophecy of sensationalistic doom -- yet, somehow nothing happens, and within a few weeks the stories are forgotten.
So far, Hand of Thief seems no different from its assorted predecessors. It is definitely following the usual story arc, helped along by RSA's uncertainty about whether it should be professionally impartial or blurt out unanswered questions like, "does Hand of Thief represent the early signs of Linux becoming less secure as cybercrime migrates to the platform?"
Taking an educated guess
Based on the information released so far by RSA, I'd answer that question with a tentative, "No."
One clue to the nature of the trojan is that its developers are not exploiting it for themselves. RSA's report seems to wonder if targetting Linux would be worth the effort, but that is only true if you are thinking in terms of home users. Considering the giant sites that run Linux, the possible profits would be endless. I mean, a back door into Amazon? Google? Facebook? The potential for reselling millions of people's personal information alone must be tremendous.
Yet, instead, the developers are leaving the exploitation to others. Either they are cautious about doing anything illegal, or resales are a more certain path to profit. Given the potential of direct exploitation, I'm guessing the latter, especially since from the published excerpt or two, the developers are careful to give buyers value for their money, explaining even the simplest concepts such as compiling in terms that almost anyone can understand.
But the most telling bit of evidence was the advice Hand of Thief's marketer gave to RSA's representative when they bought the trojan on the black market: spread it by email and social engineering.
This information has been largely ignored in the rush to sensationalism, but it deserves closer attention. What is being suggested is to get a Linux user to click on a link, or else to deceive them in person, either by talking to them or by checking under their keyboard for a Post-It note with their password.
In other words, for all Hand of Thief's careful testing and detailed help, it does not appear to have discovered any weakness in the Linux code to exploit. Instead, it seems to be relying on the ignorance and carelessness of users for access.
Or, to put things another way, Hand of Thief is probably what is sometimes called proof-of-concept malware. In theory, it can trample the Internet in its wake once it is installed. However, its installation in the first place relies on the failings of human beings, not of of Linux installations.
Unless something changes, it seems to leave the average system no more at risk than it was a month ago. With the exception of RSA, I suspect its purchasers are likely to be disappointed, although they may take a while to realize how little they have bought.
Same old same old
That is not to say that you should ignore the story. Plenty of systems are less secure than they should be -- often because users ignore security because of its minor inconveniences. Taking the time to check and tighten security is never a bad idea, and, in this case, a few basic measures by system administrators might help to reassure average users. I am not talking, of course, about security theater -- measures like the ones at American airports that look impressive but do little -- but concrete, well-established measures.
If you don't know the improvements you can make, spend some time looking at AppArmor or SE Linux to increase your knowledge of system security. One quick and educational fix is Bastille, which for more than a decade has been securing small systems with a wizard that can dramatically improve system security in a matter of an hour or two.
Check up, too, on the users who know just enough to mess with the security precautions you have set. You probably know who they are.
Another thing you can do is learn just how Linux is put together, so you assess future alarmist stories more accurately. My late colleague Joe Barr wrote a primer in 2007 that remains valid today.
So far, the most recent story can be summarized as leaving the basic security situation unchanged. You probably can stand to tweak a few settings, and to educate users who see security measures as annoying restrictions
Just remember, against user stupidity, the system admins themselves contend in vain -- but, then, we've always known that.comments powered by Disqus
Issue 177/2015
Buy this issue as a PDF
NoScript Flaw
Mozilla's script blocker add-on could be putting malware sites on the whitelist.
RIP SSLv3
The Internet community officially banishes the notoriously unsafe Secure Sockets Layer protocol.
Mate 1.1 Arrives
Popular desktop environment continues the Gnome 2 legacy – with new support for the Gnome 3 toolkit.
US Government Requires HTTPS
The Obama White House has issued a memorandum telling all US government agencies they must use HTTPS for all websites and web communication.
Mozilla Signs Firefox Add-Ons
New program will dial up security for the Firefox browser.
Fedora 22 Arrives
Red Hat's community distro embraces the cloud.
Code.org and College Board Team Reach Out for Talented High School Coders
New partnership will bring more and better CS training to US schools
A Peek Inside TeslaCrypt Ransomware
Criminals offer online help over Tor network
Mumblehard Still Spams
Sophisticated malware is still present on Joomla and WordPress sites around the world.
Launchpad Gets Git
Future versions of Ubuntu's code service will support the popular Git version control system used with Linux and other open source projects.


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A quote I like:
"If the world were merely seductive, that would be easy. If it were merely challenging, that would be no problem. But I arise in the morning torn between a desire to improve the world and a desire to enjoy the world. This makes it hard to plan the day."
― E.B. White
On to some random facts:
My name is a sentence, and I try to make it true when I can. (What could that mean? I'm so mysterious.) I like to sing and play music, though not necessarily well. I play guitar in a just-for-fun band. We do a mean the fox. I like to run barefoot. You should try it. It's amazing.
It's hard to say exactly what I'm looking for in a girl. I've liked different types. That being said, here are a few things I usually find attractive in a lady.
1) Independence. I'm all for spending a lot of time with the girl I'm dating, but I don't want to feel like you'll have a meltdown if my phone dies. Hopefully you have your own aspirations too. You should have your own opinions. If we can take different sides of an argument and have an exchange, I find that extremely attractive. (As long as you're not just being irrationally stubborn, this ties into the next one.)
2) Intelligence. It's hard to define this since there are so many types of intelligence and most people think they are smart. I just want someone who enjoys thinking. The ability to entertain an idea without necessarily accepting it is nice.
3) Passion. Hopefully there is something you really, really, enjoy or care about. It can be anything. I just like to see fire in someone's eyes.


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April 2012 Indie Next List
"One day as 12-year-old Mary walks home from school, she meets a mysterious woman who seems to appear out of nowhere. The woman looks young, but seems old, and her name is Tansey, which, as it happens, is the name of Mary's long-dead great-grandmother. Tansey says she has a message for Mary's granny. And so, impossibly, four generations of women embark on a midnight road trip to revisit the farm that made them who they are. Doyle's delightful story is charming, witty, and poignant, a surprisingly fresh generational tale that mothers and daughters will want to share!"
— Megan Graves, Hooray for Books!, Alexandria, VA
Mary O'Hara is a sharp and cheeky 12-year-old Dublin schoolgirl who is bravely facing the fact that her beloved Granny is dying. But Granny can't let go of life, and when a mysterious young woman turns up in Mary's street with a message for her Granny, Mary gets pulled into an unlikely adventure. The woman is the ghost of Granny's own mother, who has come to help her daughter say good-bye to her loved ones and guide her safely out of this world. She needs the help of Mary and her mother, Scarlett, who embark on a road trip to the past. Four generations of women travel on a midnight car journey. One of them is dead, one of them is dying, one of them is driving, and one of them is just starting out.
About the Author
RODDY DOYLE worked for fourteen years as an English and Geography teacher at Greendale Community School, in Kilbarrack, North Dublin. He achieved widespread recognition when his novel "The Commitments "(1987) was made into a motion picture in 1991. Doyle's novel "Paddy Clarke Ha Ha Ha" won the Booker Prize, Britain's highest literary award in 1993.


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Select Local Merchants
The DetailerRead MoreAt The Detailer, owners Matt and Brandi Snedden draw on more than 24 years of auto-industry experience to meet drivers' cosmetic car needs. Performing a comprehensive menu of detailing services, the specialized technicians take care to hand wash paint and use chamois to delicately dry droplets like a concerned pet owner catching its lizard's tears. The expert staff includes two paint-and-body specialists who handle aesthetic requests such as paint correction and restoration, as well as an audio/video technician who installs high-tech upgrades, including GPS navigation and remote car starters. All of Detailer's services are available on location, or techs will travel to homes or offices with the shop's mobile unit in tow, allowing customers to easily fit maintenance-and-upkeep measures into their schedules.525 West Main StreetCollinsville, OK US
Robertson TireRead MoreWhat began as Tulsa native Ted Robertson's humble downtown garage in 1962 has earned its place as a local automotive institution, where ASE-certified mechanics ensure long engine life with expert maintenance, repair, and tire services at all 11 Robertson Tire locations. Members of the Robertson family still proudly oversee the business, celebrating a half-century in operation, three generations of family ownership, and a mantel dangerously overflowing with awards. Tires from renowned brands such as BFGoodrich and Hankook?as well as fuel-efficient models from Michelin and Goodyear?cap car axles with firm traction and computer-balanced fits, and flushes, repairs, oil changes, and inspections keep engines purring. In addition to repairing cars, trucks, and utility vehicles, the community-minded staff supports local and national charities such as Operation Smile and reduces carbon tire treads with eco-friendly products and tires.11142 S Memorial Dr.Bixby, OK US
Performance AutoRead MorePerformance Auto and Diesel Steve Jones, who formerly helmed Owasso Automotive Care, and his team of expert techs fix and maintain cars, trucks, and diesel vehicles in their new Catoosa shop. Mechanics rescue rides from maladies large and small, with preventive maintenance from tune-ups and oil changes to in-depth power steering and transmission repairs. Drivers can wait for their cars in a peaceful slate-blue lobby accented with dark furniture and autographed photos of Chitty Chitty Bang Bang.2660 N Highway 167Catoosa, OK US
Clear Water Car Wash, LLCRead MoreFor more than three decades, Clear Water Car Wash has empowered patrons with the choice of automatic or self-serve washes with full access to cleaning products and eco-friendly services. After cars go through the gauntlet of dirt defeaters, drivers augment outer shines with self-serve options including car-care vending machines and free dual-motor vacuums.19967 E Pine St.Catoosa, OK US
Hesselbein TireRead MoreServicing autos for more than 35 years, Hesselbein Tire caters to cars with a seasoned team of ASE– and TIA–certified mechanics. The full-service automotive shop overseas a sprawling stockpile of more than 150,000 name-brand tires from the likes of Bridgestone and Firestone and handles the round rubber souls of all types of vehicles, from passenger vehicles and heavy trucks to lawn and garden vehicles, golf carts, and ATVs. Engine experts cater to all corners of the car with an extensive array of services including computerized alignments, battery service, transmission maintenance, and brake service. Hesselbein's staff pumps passageways full of Pennzoil during standard oil-change services and inspects overactive air conditioners that continually attract families of small Yetis.12821 E 31st StTulsa, OK US
Tulsa Auto DetailRead MoreUnder new ownership and with more than a decade of experience under their collective car-cleansing belt, Tulsa Auto Detail's staffers restore grimy rides to their shinier selves. The team cleans up sloppy jalopies with a range of detailing services, from basic hand-wash treatments to thorough exterior and interior scrub downs. During automotive makeovers, drivers may drop off cars and pick them up a few hours later or patiently watch cable-TV shows inside the waiting area. Tulsa Auto Detail's three-day wash guarantee grants customers a complimentary car wash within three days of their detailing service if cars run into rain or join a synchronized-swimming team.3635 South Sheridan RdTulsa, OK US


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Some good tidbits. Most people have no clue what the inquistions entailed or were really about. The tales grow taller all the time. The Muslims had conquered Spain and occupied it. Only one tiny section remained and it took hundreds of years to regain control. To avoid losing land and power Muslims pretended to convert. It would be like if suddenly a mass group of Muslims came into any Christian church and suddenly converted. Do you suppose the Muslims would look on a bunch of white Christians with a little suspicion today if they converted to Islam?:-) Sure I have heard some protestants boasting on these forums that they go to Catholic Churches and work on converting people from the inside. Yes there were some very strange beliefs as well, but the involvement of the church at all was more or less to stop the mob mentality which was going on. If anything the Churches involvement added civility and protections that otherwise would not have been there. Here is brief snipit from an article the link below.<quoted text>
Please provide a link where the Church murdered and tortured.
I have a quote ready from Pope Sixtus IV condemning the Spanish Monarchy for what they were doing. I assume that is the Inquisition you're referring to?
Why don't you actually read something on history, instead of relying on your cult pamphlets you all hand out to people.
"Spain had just concluded a bloody battle with the Moslems. The Moslems were known for their ruthless killing of every man woman and child of the Catholic towns that they had captured. Complicating this issue was the fact that the Jews had fought on the side of the Moslems. At night the Jews would open up the city gates of the Catholic towns to the invading Moslem Moors.
In the centuries before, the Jews had been granted permission by the Catholics in Spain to come there as refugees. Unlike the Catholics who considered usury as sinful, the Jews became very powerful in the business of money lending.
In Aragon they charged twenty percent, in Castile thirty-three percent, and in the famine of 1326, in Cuehca they refused to lend money for sowing except at forty percent interest. Added to this was their practice of insulting the Christian religion. Even today the epithet,Christian dog(perro cristiano), comes from those times.
Because of the devastating years of battle with the Moslems, and those Jews who assisted them, Spain had rescinded the Jews permission to stay there and ordered them to leave Spain in order to preserve the fragile government.
Some Jews had faked conversion. Because the government did not want to make itself vulnerable to possible traitorous acts committed by those who were still aligned with Moslem forces it needed to make determinations as to whether or not those who claimed to be converted to Christianity were being honest. It was the Inquisitors job to make this determination. The Inquisition had no jurisdiction, and therefore no authority over any practicing Jew or Moslem because they were not baptized. The Inquisition only investigated professed Christians suspected of being fakes. The Inquisitors did use some torture in their examinations, but any statement that was made during this torture was not accepted as evidence if the individual later retracted any such confession. It was the state and not the Church that carried out the sentence or punishment against those who were found guilty.


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Houston, TX (Sports Network) - Matt Dominguez launched a three-run home run in the fourth inning that proved to be the difference as the Houston Astros topped the Kansas City Royals, 6-5, in the opener of a three-game set from Minute Maid Park.
Dominguez and Jimmy Paredes had two hits apiece to pace Houston, which won for the third time in five tries after dropping six in a row. Jason Castro added his fourth homer of the season.
Jose Veras saved it with a perfect ninth for Dallas Keuchel (1-1), who yielded four runs on nine hits and four walks over 6 2/3 innings.
"They're always great, so it's nothing new," Keuchel said of the defense behind him. "I have faith in them any time. I try to get as many ground balls as possible, that's my goal."
Jeremy Guthrie (5-2) absorbed his second consecutive loss after giving up all six runs on eight hits in five innings.
"He battled his command," said Royals manager Ned Yost about Guthrie. "He was really struggling with his arm spot and he struggled at times to get the ball down."
After Miguel Tejada delivered a three-run shot of his own in the top half of the fourth for Kansas City, Houston responded when Carlos Pena drew a one-out walk and Paredes followed with a single to put two on for Dominguez, whose shot to left put the home team in front, 6-4.
Jeff Francoeur, who along with Eric Hosmer had three hits, doubled in a run in the eighth to bring KC to within 6-5, but Hector Ambriz got Tejada to ground out and Elliot Johnson to fly out to left to avoid further damage.
Houston broke a 1-1 tie in the home half of the third. After Marwin Gonzalez singled and took second on Robbie Grossman's sacrifice bunt, he advanced to third when Johnson mishandled a pick-off attempt at second base. Jose Altuve sent a sacrifice fly to center to score Gonzalez, then Castro launched a solo shot to left.
Johnson's bloop single over the outstretched glove of Gonzalez in the top of the second plated Hosmer for the game's first run, but Houston struck back in the home half. Chris Carter, who walked and advanced to third on Pena's double, trotted home when Paredes grounded out to second.
Kansas City catcher Salvador Perez left in the bottom of the sixth inning with
discomfort in his right hip after sliding for a foul ball ... Tejada's home
run was his first since July 15, 2011 ... Both teams left seven men on base.
Former Heisman Trophy winners Matt Leinart, Eric Crouch and Rashaan Salaam are among 76 Football Bowl Subdivision players on the ballot for election into the 2016 class of the College Football Hall of Fame.
The regular season in the NASCAR Sprint Cup Series has reached its midpoint, with 13 races completed and 13 to go before the championship Chase begins.
The Houston Texans have signed defensive lineman Brandon Deaderick, who played last season with the New Orleans Saints.
The Toronto Blue Jays activated catcher Dioner Navarro from the 15-day disabled list following a 2-0 loss to the Washington Nationals in the opener of Tuesday's doubleheader.
Sacramento Kings forward Carl Landry underwent surgery on Tuesday to repair a torn ligament in his right wrist, the team said.
The Montreal Canadiens revealed on Tuesday that defenseman Jeff Petry has agreed to terms on a six-year contract extension.


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I am currently extending an e-mail system with an autoresponse feature. In a dark past, I've seen some awesome mail loops, and I'm now trying to avoid such a thing from happening to me.
I've looked at how other tools ('mailbot', 'vacation') are doing this, grepped my own mail archive for suspicious mail headers, but I wonder if there is something else I can add.
My process at this point:
- Refuse if sender address is invalid (this should get rid of messages with <> sender)
- Refuse if sender address matches one of the following:
'^root@', '^hostmaster@', '^postmaster@', '^nobody@', '^www@', '-request@'
- Refuse if one of these headers (after whitespace normalization and lowercasing) is present:
'^precedence: junk$', '^precedence: bulk$', '^precedence: list$', '^list-id:', '^content-type: multipart/report$', '^x-autogenerated: reply$', '^auto-submit: yes$', '^subject: auto-response$'
- Refuse if sender address was already seen by the autoresponder in the recent past.
- Refuse if the sender address is my own address :)
- Accept and send autoresponse, prepending
Auto-response:to the subject, setting headers
Precedence: bulkand
Auto-Submit: yesto hopefully prevent some remote mailer from propagating the autoresponse any further.
Is there anything I'm missing?


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