Eligibility

For all new patients, the first thought should always be of eligibility:

  • Is the patient eligible under the plan?
  • Is the service eligible for coverage under the plan?
  • Who is eligible for coverage under a health plan?

Is the patient eligible under the plan is fairly simple to confirm. You simply must call the health carrier directly or visit them online. Just because a patient has an ID card, does not mean they are currently still eligible for coverage.   

If checking eligibility online, you will receive pages and pages of data; take the time to thoroughly review all pages of the inquiry. You may learn that the plan provides less coverage than what may have appeared at first glance. 

Is the service eligible for coverage under the plan is also fairly easy to confirm. You can call the health carrier to obtain coverage information by phone or by fax. You can also review a copy of the patient’s plan booklet or Summary Plan Description (SPD). The question should not only be, is the service eligible for coverage? But also…

  • Do I or the patient fit the current parameters for coverage?
  • Does the service have to be performed in a particular setting to be eligible for coverage? For example, a hospital instead of a providers office.
  • Does the patient have to be a certain age to be eligible? It is not unusual, especially with some state Medicaid plans, that coverage for certain services be available only to plan members under a certain age. For example, children under the age 21 may have coverage for vision while vision services are totally excluded for all adults. 
  • Does the patient’s current condition fit the criteria for coverage? Most health carriers have a list of Medical Coverage policies on various procedures, surgeries and supplies. These coverage policies provide the criteria in which a particular, service supply or treatment, will be covered.

For example, let’s look at Dermabrasion, Chemical Peels.

Dermabrasion, Chemical Peels is covered under most health plans, provided the criteria for coverage is met. The Medical Coverage Policy may state that:

Coverage for Dermabrasion, Chemical Peels will be forthcoming for the diagnosis of Actinic Keratosis (precancerous skin lesions) but coverage will be denied for the treatment of wrinkles or a tattoo removal. The criteria may also go further and require that a certain number of lesions be present and that other treatments, medications or therapies be tried first. Medical Coverage Policies can be found online at the health carrier’s website.  

Who is eligible for coverage under a health plan can be a little more tricky. Just because someone is a family member does not make them eligible for coverage. For example, in spite of the fact that a lot of grandparents are raising their grandchildren, they may not be eligible for coverage under a plan until they are formally adopted.

The people that are normally eligible for coverage include:

Spouse- Your legal spouse. Coverage for the spouse will cease once a divorce is final. If COBRA is available, the ex-spouse would be able to apply for continued coverage under the COBRA plan.

Dependent children- Unmarried children that are under the age of attainment and are dependent on the employee for their support. This normally includes natural, stepchildren and children placed under the legal guardianship of the employee.

Newborns- State law requires that newborns be covered for the first 31 days of life. During this 31-day period, the child must be added to the plan and any applicable premiums must be paid. Dependents not added within the 31-day period might be subject to additional underwriting.

Adopted children- Normally, adopted children can be added to the plan as soon as the employee takes custody of the child; pending the final adoption.

Common Law Marriage- Typically, this is a "marriage’ without the benefit of a legal ceremony. Unless the plan recognizes common law marriages or the plan includes coverage for domestic partners, the partner would not qualify as an eligible dependent under the health plan and therefore cannot be covered.

Physically handicapped, dependent children- You can extend coverage for physically handicapped children beyond the age of 26; depending on the disability.


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