General Frequently Asked Questions on Virginia Health Insurance

Where can I obtain health insurance?

Insurance agents and companies are listed alphabetically and by location in the yellow pages of your telephone directory. The Bureau of Insurance also provides a listing of carriers licensed to write health insurance and licensed HMOs in Virginia. These listings may be obtained by calling the Bureau of Insurance, or visiting the Bureau's website. Click on "Consumer" and "Want Information About a Company?" Insurance premiums can vary substantially from company to company so it usually pays to check with several companies before making a final choice.

I had a serious health condition that appears to be stabilized; however, I am having difficulty finding an insurance company that will accept me for coverage. I am not eligible for guaranteed coverage under HIPAA. What options are available to me?

Each insurance carrier has its own underwriting guidelines. The type of condition and when/how it was treated will factor into how the insurance company will respond. Contact several insurance companies, then compare options available to you. If none of the options suit you, you may contact Anthem Health Plans of Virginia, Inc. (formerly TRIGON) at 1-800-334-7676 or Carefirst Blue Cross Blue Shield at 1-800-544-8703. You may qualify for an open enrollment program where you cannot be denied insurance. However, there may be a waiting period for pre-existing conditions. There is no risk pool in Virginia. Therefore, the Open Enrollment product may be the only way for you to secure insurance if you can not get it anywhere else.

I have changed my mind and do not wish to keep the individual health insurance policy I just received. May I get a refund?

Yes. According to Virginia law, if you are not satisfied with your individual traditional health insurance policy for any reason, you may return it to the company within 10 days of the date you received it and the premium you paid will be promptly refunded. This law does not apply, however, to individual HMO plans.

My insurance company pays 80%of charges. My provider charged $4,000 for a medical service, but the insurance company only paid $2,800. Why didn't they pay the full 80%?

Companies often establish allowable charges for certain procedures and services. These charges may be based on a "usual, customary and reasonable" (UCR) schedule, or they may be based on other criteria established by the company. It appears that your company paid 80% of the allowable or UCR charge established by the company for your medical procedure.

Providers can appeal to companies if a procedure or service was especially difficult, or other circumstances necessitated a charge exceeding the allowable or UCR charge. Your policy, certificate, EOC or benefit booklet provides information concerning appeals or requests for reconsideration of payments.

I have just received notice that my health insurance premium is increasing. I have not had any claims. How is my company justified in raising my rates?

Premium rates are calculated based on the pooling of a large number of similar risks. The claim experience of the pool, as a whole, is used to determine premium rates.

Does the Virginia Bureau of Insurance regulate all health insurance?

Group and individual health insurance plans issued and delivered in Virginia are subject to regulation by the Bureau of Insurance. Most group plans issued to associations or trusts located outside of Virginia, however, are governed by the state in which the policy was issued for delivery, regardless of whether individuals covered under these plans reside in Virginia. Also, self-insured (or self-funded) plans are regulated by the federal government.

Does the Bureau of Insurance regulate health insurance rates?

The Bureau of Insurance approves premium rates for individual health insurance policies. In all cases, rates must be applied fairly and reasonably.

My insurance company has rescinded my health insurance policy. What does this mean?

The insurer has voided coverage. Recision usually occurs as a result of incomplete or inaccurate information submitted on the application, or an omission of information that is pertinent to the underwriting of the policy.

What is a drug formulary?

Many plans or policies establish a list of prescription drugs, which the plan considers medically appropriate and cost effective. The plan will provide coverage for only those prescription drugs named in the list. However, your doctor may present medical evidence to the insurer to obtain an exception that will allow coverage for a prescription drug not routinely covered by the plan.