do I have to be covered by health insurance when claims are submitted?

March 13, 2013 9:46 AM

If my medical provider submits a claim for treatment that was received while I was insured, but the claim is submitted after my insurance expires, will insurance still pay? (Asking in the US.)

I'm leaving my job this month, and do not plan to continue my health insurance coverage with COBRA. I do not have another job lined up at this time.

This means that my last day of coverage will be March 31st. If I were to see the doctor in the next couple of weeks (when I'm still insured), but the doctor submits the claim after my insurance expires, can I expect to run into problems with my insurance company? I'm insured by Aetna, if it matters.

I am aware that no one here is my lawyer, doctor, or insurer. Thank you very much!

posted by scarylarry to Work & Money (8 answers total)

So long as the date of service is when your coverage was still in effect, there should be no problem with covered services being paid per the plan.
posted by FergieBelle at 9:55 AM on March 13, 2013

I am quite confident the preceding answer is correct--but there are instances where claims may be paid on a "submitted" rather than "received" date. i would simple call Aetna and ask--particularly if the claim might be for more than a simple/uncomplicated office visit.
posted by rmhsinc at 10:01 AM on March 13, 2013

If your coverage is valid, you shouldn't have a problem, key word being "shouldn't". I will say that in my (professional) experience, "experimental" treatments are more likely to be questionned if the patient's insurance expired (like, you see the doc 12/15, they're processing the claim 1/2 after your coverage is over). But a simple office visit should be fine.

--but there are instances where claims may be paid on a "submitted" rather than "received" date. = Really? I've never known that to be true and would be interested to hear when that might happen.
posted by ThePinkSuperhero at 10:03 AM on March 13, 2013

I have a child with special needs. I deal with insurance a lot.

In fact, I am dealing with insurance right now as I am typing this. I am on hold.

As long as the dates of service are from BEFORE the expiration of your insurance, then you are fine. It can take up to 6 weeks for claims to be processed, anyway.

You should be fine.
posted by zizzle at 10:10 AM on March 13, 2013

The Pinksuperhero--you are right--Regulated health insurance policies are on a claim occurred rather than claim made.
posted by rmhsinc at 10:20 AM on March 13, 2013

I worked for an insurance company. There can be a time limit, but it shouldn't be "must be postmarked by midnight of the last day of coverage." I would call and ask and if I went to a doctor I would let them know my concerns that it would be best to submit this in a timely fashion.
posted by Michele in California at 10:48 AM on March 13, 2013

Sometimes (maybe always) COBRA plans mean you end up with a new claim number. So you may need to provide that new information for future visits. But as others say above, if the service happens while care is valid then it's covered.
posted by phearlez at 10:49 AM on March 13, 2013

scarylarry: I'm leaving my job this month, and do not plan to continue my health insurance coverage with COBRA. I do not have another job lined up at this time.

For what it's worth, going through the motions with COBRA can provide a kind of Health Insurance Safety Net for around 90 days, if you think that might help. Basically, sign up for COBRA on the very last day possible (or near to it). I think you have 45 days. Then do not pay any COBRA premiums. I think you have another 45 days before they consider the payment so late that they terminate the plan. If you call them just before that date, you can tell them to cancel the coverage and to not charge you. They will reverse all the charges and you owe nothing. BUT, if you have a major health event in those 90 days, you can just pay the premiums and now you have health insurance coverage for that period.

NOTE: I am not an expert in this, but I have done it once and it worked out very well for us. Check with appropriate HR/benefits/insurance people and COBRA for exact details and to see if this is still the case in a post-Obamacare world.
posted by Rock Steady at 11:09 AM on March 13, 2013