Below are some questions frequently asked by EBS clients.  We hope they help clarify any questions you may have, but if you're in need of further assistance please contact EBS directly.

  1. My medical claim has been denied. Can I appeal?
  2. Can I change my medical insurance election mid-year?
  3. What is the difference between HMO, POS, PPO and EPO?
  4. I am 65 and have Medicare. Should I also enroll in the medical plan offered by my employer?

1. My medical claim has been denied.  Can I appeal?

It is possible to appeal a claim, but the first step is to check your booklet-certificate to see if there is a contractual reason for the denial.  If there is no apparent reason for the denial or if it is a situation that warrants special consideration, the first step is to write to the insurance company requesting a review.  The request must be in writing and must state the reason you feel the charge should be covered.  The insurance company will either agree with your request and pay the claim or uphold their original decision and include specific information about how to use the external appeals process through the state insurance department. Click here to contact EBS for additional information.

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2. Can I change my medical insurance election mid-year?

Although there are exceptions, most medical and dental insurance plans have Open Enrollment once a year.  It is at this time employees have the option to change their elections.  If an employee has a life status change (gets married or divorced, has a new baby, etc.) a change can be made as long as the employer is notified within 31 days of the event.  Otherwise, you must wait until open enrollment to make the change.

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3. What is the difference between HMO, POS, PPO and EPO?

  • HMO is a Health Maintenance Organization.  These plans typically require the insured to use only providers that participate in the plan, and a referral is needed before visiting a specialist.
  • POS signifies Point Of Service.  This type of plan allows you to use any provider, but benefits are greatly reduced for providers who do not participate in the network.  You make your decision at the Point of Service whether to use a network or out-of-network provider.  Like the HMO, a referral is sometimes necessary when a specialist is needed.
  • PPO means Preferred Provider Organization.  This plan is the most flexible of all the options.  Like the POS, you may use any provider with better benefits available for network providers, but unlike the POS, you never need a referral.
  • EPO, Exclusive Provider Organization, is similar to the HMO in that you are limited to network providers, but with the EPO, you do not need referrals.

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4. I am 65 and have Medicare.  Should I also enroll in the medical plan offered by my employer?

This is not an easy question to answer as it differs from one person to another depending on individual circumstances, but there are some general guidelines.  If an employer has fewer than 20 employees, Medicare is Primary, which means Medicare pays first.  Any group insurance plan pays second.  In this case, it is important that you maintain Medicare.  The group insurance would cover charges such as prescriptions that are not covered by Medicare, but other medical expenses would be reduced by the Medicare payment.  The group insurance plan may or may not be important to you.

If your employer has 20 or more employees, the group insurance plan is primary, and Medicare is secondary.  In this case, you may or may not need Medicare.  It is important to keep in mind, however, that Medicare imposes strict penalties if you do not enroll during one of several designated enrollment periods.  You should check with your local Social Security office for the current rules.

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