Health Care : Private Healthcare Insurance

What is private health insurance?

Private health insurance helps cover the costs of health care. It is regulated by the Ohio Department of Insurance.

The coverage and costs of insurance policies vary widely, so it is hard to compare policies.

Most policies have a monthly premium and co-payments and deductibles for services received. Make sure you understand what the policy covers and does not cover before you purchase it.

Policies may cover a single individual or an entire family.

Private health insurance can be provided through an employer or purchased individually directly from an insurance company.

Insurance is a contractual relationship, so you must look at your policy and member handbook to know the details of your coverage and required procedures.

What will my insurance cover?

Each insurance policy covers different services and has different costs, so you need to look at your policy and member handbook to understand what is covered.

Will my insurance pay for all of the health care I get?

Probably not. Your insurance policy will describe the services covered. Almost every insurance policy excludes some health care services.

Look at your policy to see what is covered.

Can I go to any doctor to get health care?

Probably not.

Your insurance company will have a network of doctors, hospitals, pharmacies and other health care providers that you must use with your insurance.

If you have an emergency, or are out of the area, you can go to a doctor or hospital out of the insurance company's network, but you should tell your insurance company about this as soon as possible .

What if I disagree with a decision of my insurance company?

If you disagree with a decision of your insurance company, you can file an appeal with the company and it will review your claim. If you are still not satisfied, you can file a complaint with the Ohio Department of Insurance (ODI).

What if I have health insurance through my job and I quit or lose my job or what if I have health insurance through my spouse and I get divorced?

If you have health insurance through your employer, or your spouse's or your parent’s employer, and you lose coverage, you may be able to buy continuing coverage for the same cost as the group rate.

The Consolidated Omnibus Budget Reconciliation Act of 1986 (COBRA) added a section to the United States Code to specify continuation coverage requirements for employer-provided group health plans.

Most group health plans must offer any “qualified beneficiary”—who would otherwise lose coverage under the plan as a result of a “qualifying event”—an opportunity to elect a continuation of their insurance coverage.

This applies to most employers except for:

  • small employers with fewer than 20 employees;
  • church plans; and
  • government plans.

A qualifying event must meet each of the following three categories.

1. Separation from employment

    • the death of the covered employee

    • termination of employment (other than by reason of gross misconduct or the employee)

    • reduction of hours of a covered employee's employment—reduction may make the employee ineligible for employer-paid coverage

    • a covered employee becoming entitled to Medicare benefits

    • a dependent child ceasing to be a dependent child of the covered employee

    • death, divorce or legal separation terminating coverage for spouse or dependent children

    • employer's bankruptcy in the case of retirees

2. Loss of coverage—an event satisfies COBRA if the event causes the covered employee, or the spouse or a dependent child of the covered employee, to lose coverage under the plan. Substantial changes or reduction of coverage also applies.

3. Plan is subject to COBRA—an event satisfies this section if it occurs while the plan is subject to COBRA. An event will not satisfy this requirement if it occurs before the plan has become subject to COBRA or while this plan is excepted from COBRA.

Employers have a duty to give employees and other affected individuals notice of their COBRA rights. If an employer does not give notice of COBRA rights, a court may order damages and require the employer to pay for the costs of health care.

If you think you have a COBRA issue, you should contact your local legal aid program.

See also the Forms & Education tab in this section for more information.
The information in this site is not intended as legal advice.
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