Medicare and Coordination of Benefits
So you have Medicare but are enrolled in Group Retiree Benefits, or some other type of coverage in addition to Medicare. That’s great, but who covers first, who comes in second. Do you know?
Don’t worry most people don’t know. I remember not to long ago, answering these same questions, on the telephone, and this sweet lady was so upset, because no one took the time to explain it to her.
Keep in mind, this information can be found in the “ MEDICARE AND YOU 2010 Book. The book itself has a little over 135 pages.
So Who pays first when you have other insurance????
When you have other insurance( like employer group health coverage) There are rules that decide whether Medicare or your other insurance pays first. The insurance that pays first is called “primary payer” and pays up to the limits of its coverage. The one that pays second, called the “secondary payer” only pays if there are costs left uncovered by the primary coverage.
If your other coverage is from an employer or union group health plan, these rules apply:
• If you are retired, Medicare pays first
• If your group health plan coverage is based on your or a family member’s current employment, who pays first depends on your age, the size of the employer, and whether you have Medicare based on age, disability, or End-Stage Renal Disease ( ESRD):
- If you are under age 65 and disabled, your plan pays first if the employer has 100 or more employees or at least one employer in a multiple employer plan has more than 100 employees.
- If you are over age 65 and still working, your plan pays first if the employer has 20 or more employees or at least one employer in a multiple employer plan has more than 20 employees.
• If you have Medicare because you have ESRD, your plan pays first for the first 30 months you have Medicare.
The following types of coverage usually pay first:
• No-fault insurance ( including automobile insurance)
• Liability ( including Automobile insurance)
• Black Lung benefits
• Workers’ Compensation
Medicaid and TRICARE never pay first. They only pay after Medicare, employer group health plans, and/or Medigap have paid.
This is very important!!!!!!!!!!!!!!!!!!!
If you have other coverage, tell your doctor, hospital and or pharmacy. If you have questions about who pays first, or you need to update your other insurance information, call Medicare’s Coordination of Benefits Contractor at 1-800-999-1118. TTY users should call 1-800-318-8782.
You may need to give your Medicare number to your other insurers ( once you have confirmed their identity) so your bills are paid correctly and on time.
I hope this clears up some of the confusion about who pays, when and why.
And remember if there is something that you would like me to find out for you, leave a comment and/or email me at mmcampos68@gmail.com
Friday, November 20, 2009
Thursday, November 19, 2009
Medicare Open Enrollment Period Nov 15th thru Dec 31st
Hello to all on this fine and dreary day.
As I am sure we all know Medicare Open enrollment period is here again. Who has what? how much does it cost? Drug coverage gap? Which way to go?
I feel really bad for anyone going on medicare this year or any other time as well. Why, you may ask? The over abundance of information sent via email, or thru snail mail, the million and one phone solicitation calls, the calls from different insurance carriers, sales agents, families, friends, associates, everybody has something to say, something to add on.
You know what enough already!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!
I am going to give it to you straight!!!!!!!!!!!!!!!!!!!!!!!!
I am going to start with the basics
This information comes directly from the Medicare.Gov website. If you want to help someone who is on medicare, direct them to the Medicare.gov website or give them the phone number to contact Medicare directly.
Please don't confuse people anymore because they are already confused. Medicare can be complex, to most people it is, so if you don't know the answers reference them to someone that does.
Medicare is run by The Centers for Medicare & Medicaid Services (CMS), it is a Federal Agency that runs Medicare. It is part of the U.S. Department of Health and Human Services
Medicare is a health insurance for people aged 65 or older, under 65 with certain disabilities, and any age with End-Stage Renal Disease ( which means permanent kidney failure requiring dialysis or a kidney transplant)
Medicare can best be described as having four parts to it. I will explain this in laymen's terms for the average person.
Part A is for Hospital Insurance
Part B is for Medical Insurance
Part C is for a Medicare Advantage plan like an HMO or a PPO
Part D is for Medicare Prescription Drug Coverage
but you may be asking do i need to have all four parts, the answer is no!!!
Medicare Part A helps cover inpatient care in hospitals. This includes criticalaccess hospitals and inpatient rehabilitation facilities. It also helps cover hospicecare and home health care, and skilled nursing facilities
What is Medicare Part B?
Medicare Part B helps cover medically-necessary services like doctors’ services,outpatient care, and other medical services. Part B also covers some preventiveservices. These include a one-time “Welcome to Medicare” physical exam, bonemass measurements, flu and pneumococcal shots, cardiovascular screenings,cancer screenings, diabetes screenings
While there is no cost associated with Part A, Part B of Medicare does have a premium that comes out of your pocket The Premium in 2009 is 96.40, this normally comes out of your Social Security check monthly.
So we know what Medicare covers, but do we also know what Medicare does not cover?
Keep in mind that Medicare doesn't cover everything. Medicare does not cover cosmetic surgery, health care you get while traveling outside of the United States, except in limited cases, hearing aids, most hearing exams, long-term care ( like nursing homes), most eyeglasses, most dental care and dentures.
Please remember though that some of these services can be provided for you by a Medicare Advantage Plan like an HMO or a PPO.
And if you read my previous post you would know the difference between a PPO and an HMO
Don't Worry, i will explain that once more.
No for the fun part, and yes i am being a little sarcastic, because if Medicare was confusing before, it became harder to understand when they came with Part D - Medicare Prescription Drug Coverage.
Medicare offers prescription drug coverage ( Part D) for everyone with Medicare. This coverage may help lower your prescription drug costs and help you protect against higher costs in the future.
It can give you greater access to drugs that you can use to prevent complications of diseases and to stay well.
In order to get Medicare drug coverage, you must join a plan run by an insurance company or other private company that is approved by Medicare.
now here is the fun part, which i personally think that this is a field that should be better managed by our government and you will understand why i say that when i tell you the following:
Each plan can vary in cost and drugs covered. If you join a Medicare drug plan, you usually pay a monthly premium. I will say this, please please please check the formulary drug list before you sign up with any plan to make sure that your meds are listed.
If you don't understand how to look up your medications with any formulary list for any prescription drug plan, ask a licensed agent to help you, find someone that is knowledgeable and who will take the time to help you, if you can't find anyone. send me a note, i will find you an agent to help you.
This is a huge pet peeve for me, as an agent, it aggravates me to no end, when insurance companies and other agents don't take the time to help you.
Keep in mind that if you decide not to join a Medicare Prescription plan when you first become eligible, you may pay a penalty if you choose to join at a later date.
If you have limited income and resources, you may qualify for extra help with your drug costs. If that is the case don't worry, I am going to post all the necessary information at the end of this post, where to go to get help.
So what are your Medicare Health plan choices?
You can choose different ways to get your Medicare health coverage. Most people get their coverage through Original Medicare or a Medicare Advantage plan like an HMO or PPO, your costs will vary depending on your coverage and the services you use.
Original Medicare- provides Medicare Part A and Medicare Part B coverage, it is a fee-for-service plan managed by the Federal Government. This means you are usually charged a fee for each health care service or supply you get. in addition to that, for some services, you will pay an amount called a deductible before Medicare pays its part. Then, when you get a medicare covered medical supply or service, Medicare pays its share of the cost of the supply or service and you pay your share.
This is one of the reasons most people on medicare opt to get a Medicare Advantage plan or even a Medigap (Medicare Supplemental Plan) to offset those deductibles, copays and coinsurance costs.
Now keep in mind that with Medicare Advantage plans, or Part C plans, you may be required to stay within a certain network and only see certain doctors and hospitals and would not be allowed to go out of network. You may also need a referral to see a specialist. You may also need Prior Authorization to get certain tests, exams, labs, ultrasounds, surgeries.
This is something you would need to ask your insurance provider or agent before you enroll into a plan.
So when can you make changes to your plan???????????
You can make changes to your MEDICARE health or Prescription drug coverage between NOVEMBER 15- Thru DECEMBER 31ST of each Year. If you are eligible for a Medicare Advantage plan, you can also join a Medicare Advantage plan between January 1st thru March 31st. each year.
Phone numbers and websites
http://www.socialsecurity.gov/
Getting help with prescription drug costs
1-800--772-1213
TTY Users 1-800-325-0778
This is only Part One of 6 of my medicare post
Part 2,3,4, will be in much more detail.
see you soon!!!!!!!!!!
As I am sure we all know Medicare Open enrollment period is here again. Who has what? how much does it cost? Drug coverage gap? Which way to go?
I feel really bad for anyone going on medicare this year or any other time as well. Why, you may ask? The over abundance of information sent via email, or thru snail mail, the million and one phone solicitation calls, the calls from different insurance carriers, sales agents, families, friends, associates, everybody has something to say, something to add on.
You know what enough already!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!
I am going to give it to you straight!!!!!!!!!!!!!!!!!!!!!!!!
I am going to start with the basics
This information comes directly from the Medicare.Gov website. If you want to help someone who is on medicare, direct them to the Medicare.gov website or give them the phone number to contact Medicare directly.
Please don't confuse people anymore because they are already confused. Medicare can be complex, to most people it is, so if you don't know the answers reference them to someone that does.
Medicare is run by The Centers for Medicare & Medicaid Services (CMS), it is a Federal Agency that runs Medicare. It is part of the U.S. Department of Health and Human Services
Medicare is a health insurance for people aged 65 or older, under 65 with certain disabilities, and any age with End-Stage Renal Disease ( which means permanent kidney failure requiring dialysis or a kidney transplant)
Medicare can best be described as having four parts to it. I will explain this in laymen's terms for the average person.
Part A is for Hospital Insurance
Part B is for Medical Insurance
Part C is for a Medicare Advantage plan like an HMO or a PPO
Part D is for Medicare Prescription Drug Coverage
but you may be asking do i need to have all four parts, the answer is no!!!
Medicare Part A helps cover inpatient care in hospitals. This includes criticalaccess hospitals and inpatient rehabilitation facilities. It also helps cover hospicecare and home health care, and skilled nursing facilities
What is Medicare Part B?
Medicare Part B helps cover medically-necessary services like doctors’ services,outpatient care, and other medical services. Part B also covers some preventiveservices. These include a one-time “Welcome to Medicare” physical exam, bonemass measurements, flu and pneumococcal shots, cardiovascular screenings,cancer screenings, diabetes screenings
While there is no cost associated with Part A, Part B of Medicare does have a premium that comes out of your pocket The Premium in 2009 is 96.40, this normally comes out of your Social Security check monthly.
So we know what Medicare covers, but do we also know what Medicare does not cover?
Keep in mind that Medicare doesn't cover everything. Medicare does not cover cosmetic surgery, health care you get while traveling outside of the United States, except in limited cases, hearing aids, most hearing exams, long-term care ( like nursing homes), most eyeglasses, most dental care and dentures.
Please remember though that some of these services can be provided for you by a Medicare Advantage Plan like an HMO or a PPO.
And if you read my previous post you would know the difference between a PPO and an HMO
Don't Worry, i will explain that once more.
No for the fun part, and yes i am being a little sarcastic, because if Medicare was confusing before, it became harder to understand when they came with Part D - Medicare Prescription Drug Coverage.
Medicare offers prescription drug coverage ( Part D) for everyone with Medicare. This coverage may help lower your prescription drug costs and help you protect against higher costs in the future.
It can give you greater access to drugs that you can use to prevent complications of diseases and to stay well.
In order to get Medicare drug coverage, you must join a plan run by an insurance company or other private company that is approved by Medicare.
now here is the fun part, which i personally think that this is a field that should be better managed by our government and you will understand why i say that when i tell you the following:
Each plan can vary in cost and drugs covered. If you join a Medicare drug plan, you usually pay a monthly premium. I will say this, please please please check the formulary drug list before you sign up with any plan to make sure that your meds are listed.
If you don't understand how to look up your medications with any formulary list for any prescription drug plan, ask a licensed agent to help you, find someone that is knowledgeable and who will take the time to help you, if you can't find anyone. send me a note, i will find you an agent to help you.
This is a huge pet peeve for me, as an agent, it aggravates me to no end, when insurance companies and other agents don't take the time to help you.
Keep in mind that if you decide not to join a Medicare Prescription plan when you first become eligible, you may pay a penalty if you choose to join at a later date.
If you have limited income and resources, you may qualify for extra help with your drug costs. If that is the case don't worry, I am going to post all the necessary information at the end of this post, where to go to get help.
So what are your Medicare Health plan choices?
You can choose different ways to get your Medicare health coverage. Most people get their coverage through Original Medicare or a Medicare Advantage plan like an HMO or PPO, your costs will vary depending on your coverage and the services you use.
Original Medicare- provides Medicare Part A and Medicare Part B coverage, it is a fee-for-service plan managed by the Federal Government. This means you are usually charged a fee for each health care service or supply you get. in addition to that, for some services, you will pay an amount called a deductible before Medicare pays its part. Then, when you get a medicare covered medical supply or service, Medicare pays its share of the cost of the supply or service and you pay your share.
This is one of the reasons most people on medicare opt to get a Medicare Advantage plan or even a Medigap (Medicare Supplemental Plan) to offset those deductibles, copays and coinsurance costs.
Now keep in mind that with Medicare Advantage plans, or Part C plans, you may be required to stay within a certain network and only see certain doctors and hospitals and would not be allowed to go out of network. You may also need a referral to see a specialist. You may also need Prior Authorization to get certain tests, exams, labs, ultrasounds, surgeries.
This is something you would need to ask your insurance provider or agent before you enroll into a plan.
So when can you make changes to your plan???????????
You can make changes to your MEDICARE health or Prescription drug coverage between NOVEMBER 15- Thru DECEMBER 31ST of each Year. If you are eligible for a Medicare Advantage plan, you can also join a Medicare Advantage plan between January 1st thru March 31st. each year.
Phone numbers and websites
http://www.socialsecurity.gov/
Getting help with prescription drug costs
1-800--772-1213
TTY Users 1-800-325-0778
This is only Part One of 6 of my medicare post
Part 2,3,4, will be in much more detail.
see you soon!!!!!!!!!!
Health Insurance Basics Part 2 - What most people are not aware of
Health Insurance Basics - Part 2 what big companies don't tell you, and you don't know to Ask
Wednesday, November 18, 2009
The Basics of Health Insurance Part One
The Basics of Health Insurance
There are many types of health insurance plans out there and available to Individuals, Families, Small groups, Associations, Mom and Pop stores and Large companies. Most if not all plans are expensive.
The big question is how does the average person know which plan to pick for their specific individual needs?
How many different health insurance plans are there? Well, I can tell you that there are a whole lot of different ones out there. It's not the fact that there are alot of different ones out there, but that there are alot of different types of plans out there.
to give you an idea of how many different types of plans there are, here are a few of them.
There is the PPO, HMO, POS, FSA, HSA, High deductible 100%, High deductible 80%. In the dental arena we have the DHMO, DPPO, DPOS, the discount cards for dental, vision, and prescriptions, which also provide some type of benefit for chiropractic visits and legal services as well.
We also have the Hospital Indemnity plans, which are designed for persons who have been turned down for medical insurance due to pre-existing conditions, some are excellent and some are terrible plans.
Then and let's not forget our seniors also have a very hard time trying to decipher what is available to them. Medicare is a great program, but our seniors have to figure out if they are just going to stick with medicare and medicare alone, or are they going to get a Medigap or Medicare supplemental plan, or are they going to go with a Medicare Advantage plan that combines the medical and prescription benefits together, or a separate drug plan, and if they decide to go with a Medicare Advantage Plan, are they going to get one that covers the drug coverage gap? are they getting an HMO? POS? PPO?
All these questions? so where do you get the answers?
Most of us, know that if we ask a insurance agent, they will in fact try to sell us a plan, normally it will be a plan from a carrier that they are contracted with. Is that right or wrong? Well if you ask an Insurance agent, it's logical that they will sell you a plan. Will they compare rates for you against other carriers, most will.
Will they tell you if their competition is cheaper? some will, some won't. Is it right?
I am going to go over the different plan types and will try to keeep it as simple as possible.
To keep it as simple as possible i am going to give a definition of each plan and explain the terminology within the terminology, because we all know that with any plan, there are maximum out of pocket charges, or as i like to call them (out of pocket Surprises), co-insurance, deductibles, co-pays and other such terms which can confuse even the smartest person.
So let's get started, and remember i am keeping it simple, this is just an overview of the different plans, i will get into each plan more thoroughly through future postings.
Traditional Major MEDICAL PLANS- In a major medical plan the insured (you) is responsible for paying a deductible before the insurance plan pays any benefits. Then the insurance company pays 70, 80 or 90% and the insured (you) would be responsible for the remaining 10,20 or 30%
Deductibles- The amount you are responsible to pay before the insurance company starts to pay their share.
HMO's Also known as a Health Mantenance Organization, is a type of insurance plan that focuses on the long term care of its insured and is normally less expensive than a Major Medical Plan. Each insured has a Primary Care Physcian, who is responsible for providing preventative care and coordinating care for the insured. If additional specialists or hospitalization is neccessary. You the insured may need to get prior authorization, you may need a referral from your primary care physcian.
This keeps the costs down, You would have co-pays, and you may have to stay in network.
The HMO is known as the co-pay plan and the majority of HMO's only cover in-network doctors and hospitals, and you are required to get a referral before seeing a specialist or your claim can be denied.
PPO Plans- Preferred Provider Organizations, is similar to an HMO, as there is a network of physcians and hospitals, but unlike an HMO, an insured (YOU) is not limited to only in network physcians and hospitals and can go out of network and see who they would choose to see. Keep in mind though, if you stay in network, your copays and deductibles will be less for in network services.
In addition, network physcians determine reasonable charges, therefore is an out-of-network physcian charges more for services, the insurance company will still pay only 80% of the in-network charges any additional fees the insured would be responsible. In that scenario the insured will often pay higher fees for out-of network services.
Most people prefer the freedom to choose their own doctors and not be limited to one network.
POS Plans- Point of Service Plans
Is considered to be a combination of a PPO and an HMO. The insured (you) chooses a Primary Care Physcian and all health care should start with the patient consulting the physcian. The doctor authorized a referral to see a specialist, in or out-of-network. Keep in mind that with an HMO, the specialist must be in network in order for the service to be covered.
If a patient chooses to see a specialist without a referral, the insurance company may choose not to pay for the services. A POS plan is also considered to be a managed health care plan, but the insured has the capability of having more options than the standard HMO Plan.
Health Savings Accounts - HSA's
A health Savings Account is an alternative to traditional health insurance, it is a savings product designed to offer a different way for consumers like yourself to pay for their own healthcare. HSA's enable you to pay for current health expenses and to save for future qualified medical and retiree health expenses on a tax-free basis.
A Health Savings Account combines a high deductible health insurance with a tax-favored savings account. Money in the savings account helps pay the deductible. Once the deductible is met, the insurance company starts to pay. Money left in the savings account earns interest and is yours to keep.
An HSA account can increase your health insurance buying power by:
To get the benefits of an HSA, the law requires that the savings account be combined with a high deductible health insurance plan. High deductible health insurance plans cost less than the traditional $250-$500 deductible coverage, because the insurance company doesn't have to process and pay claims for routine, low-dollar medical care.
The Co-pay Plans
Co-pay plans provide traditional insurance benefits for people who need routine health care. Co-pay plans are similar to traditional coinsurance offered by an employer that includes a copayment amount for out-of-pocket medical expenses. If you are looking for a plan that offers co-pay benefits, preventative care, and prescription drugs, then the copay plan is best suited for you.
When you use a preferred network doctor for an office visit, carriers will pay 100% for history and exam fees after a specific co-pay amount. Office expenses outside your network will not be eligible for co-pay benefits typically.
additional features include:
- Prescription Drug card benefits
- Comprehensive coverage for inpatient and outpatient medical expenses
Short term Health Insurance
Life can change quickly and you may need the protection of a short term health insurance plan. Short term medical insurance products can be an alternative to Cobra health insurance and can provide temporary health insurance for individuals who may have:
Guaranteed Issue Plans-
These plans are a nickel a dozen, there a whole lot of these plans out there, and most people are very confused about them. the majority of Guaranteed issue plans are not traditional insurance plans, what they are in actuality are Hospital idemnity plans with or without additional medical benefits.
These plans do not have medical questions that need to be answered, there is no underwriting, the enrollment into these plans is usually one page or less. Whenever you use these plans, the benefits are paid directly to you. Some people call these reimbursement plans.
If you can't afford traditional health insurance, or have been turned down for health insurance due to pre0-existing conditions, these plans are good alternatives.
Terminology that you should know
Benefit Period- a specified period of time during which benefits for covered services must be used. Example, a calendar year ( january-december) or a contract year ( 12 consecutive months following your effective date of enrollment).
Benefit Period Maximum- The total amount your insurance plan will pay for covered medical expenses during each benefit period.
Calendar Year
The 12-month period begining on January 1st and ending December 31st.
Coinsurance - A cost- sharing requirement under which you are responsible for paying a certain percentage of the covered medical expenses, after you meet your deductible (if applicable).
example
you have a 100,000 hospital bill and a plan with a $5000.00 deductible and 80/20 co insurance
100,000 hospital bill
5,000 deductible
95,000 balanace
You would pay 20% of the 95,000 with a maximum out of pocket that varies from carrier to carrier and the carrier would pay 80% , and then 100% above your maximum out of pocket.
There would be additional costs over and above this if you use providers who are out of the carrier's network they provide. This is very important issue for most people. You should always speak to an agent or broker concerning each carriers plan design.
Contract Year - The period of 12 consecutive months following the effective date of your agreement and each subsequent 12-month period that the agreement is in effect.
Co-payment - a cost sharing requirement under which you are responsible for paying a set dollar amount for covered medical expenses. Some plans require you to meet your deductible first and others don't.
Deductible- amount you must pay out of your own pocket before the plan begins to pay for any covered services.
Effective Date - The date, as shown in your carrier records, on which ytour health care coverage begins.
Guaranteed Issue- Plans that accept all applicants without regard to the applicants state of health.
Medically Underwritten - Plans that base acceptance for enrollment on your health status, determined by the answers you give on a medical questionnaire.
Health Savings Account (HSA) A savings account for out-of-pocket medical expenses in which contributions and interest earned are tax-exempt and withdrawals are tax-free if funds are used for eligible medical expenses. An HSA is used in conjunction with a high deductible health plan.
High Deductible Health Plan ( HDHP) - a health plan that offers substantial savings in monthly premiums in conjunction with higher than usual deductible levels. When you enroll in a qualified HDHP, you may be able to take advantage of the tax savings offered by a health Savings Account (HSA).
Health Maintenance Organization (HMO) - a health care program that provides coverage only for those eligible services received within the insurance carrier's provider network. There is no reimbursement to you if you use a doctor or hospital that does not participate in the carrier's network ( unless it is an emergency).
Lifetime Maximum- The total amount your insurance plan will pay for covered medical expenses while you are enrolled in your plan. With some carriers they also limit how much of the lifetime maximum you can use per year.
Networks- These are companies that have negotiated lower rates with providers such as doctors, hospitals, outpatient care facilities, and other health care providers. Some insurance carriers have their own network contracts with these providers. Every insurance carrier will either use their own network or they will buy the services of an independent network company to keep their costs lower when you utilize the plan.
These discounted rates get passed down to you if you buy a plan where you're deductible needs to be met first. When calling a provider to check whether or not they participate with your insurance carrier, always tell them what network your carrier uses. It is not unusual for a provider not to recognize your carrier but will recognize the network provider.
Non-participating Providers - Providers that do not have agreements with the network your carrier is providing to you. These providers may "balance Bill" you for any differences between the carriers payment amount and the provider's actual charges. Insurance carriers who pay UCC verse RCC give you more protection against and financial surprises when you utilize your plan.
UCC- Usual, Customary Charges
RCC- Reasonable, Customary Charges
Out-Of-Pocket Maximum -The maximum amount you will pay out of your own pocket for covered medical expenses during a given benefit period. Normally this requires that you stay within the network your carrier provides. Some companies have limits even if you are out of the network while others don't.
Participating Providers- Providers that have agreements with networks to accept carriers payment amounts as payment-in-full for covered services ( after any applicable deductible, co-payments or co-insurance).
Pre-Existing Condition - a condition for which medical advice or treatment was recommended by a physcian or other medical provider within a carrier specified time frame immediately before your effective date.
There are many types of health insurance plans out there and available to Individuals, Families, Small groups, Associations, Mom and Pop stores and Large companies. Most if not all plans are expensive.
The big question is how does the average person know which plan to pick for their specific individual needs?
How many different health insurance plans are there? Well, I can tell you that there are a whole lot of different ones out there. It's not the fact that there are alot of different ones out there, but that there are alot of different types of plans out there.
to give you an idea of how many different types of plans there are, here are a few of them.
There is the PPO, HMO, POS, FSA, HSA, High deductible 100%, High deductible 80%. In the dental arena we have the DHMO, DPPO, DPOS, the discount cards for dental, vision, and prescriptions, which also provide some type of benefit for chiropractic visits and legal services as well.
We also have the Hospital Indemnity plans, which are designed for persons who have been turned down for medical insurance due to pre-existing conditions, some are excellent and some are terrible plans.
Then and let's not forget our seniors also have a very hard time trying to decipher what is available to them. Medicare is a great program, but our seniors have to figure out if they are just going to stick with medicare and medicare alone, or are they going to get a Medigap or Medicare supplemental plan, or are they going to go with a Medicare Advantage plan that combines the medical and prescription benefits together, or a separate drug plan, and if they decide to go with a Medicare Advantage Plan, are they going to get one that covers the drug coverage gap? are they getting an HMO? POS? PPO?
All these questions? so where do you get the answers?
Most of us, know that if we ask a insurance agent, they will in fact try to sell us a plan, normally it will be a plan from a carrier that they are contracted with. Is that right or wrong? Well if you ask an Insurance agent, it's logical that they will sell you a plan. Will they compare rates for you against other carriers, most will.
Will they tell you if their competition is cheaper? some will, some won't. Is it right?
I am going to go over the different plan types and will try to keeep it as simple as possible.
To keep it as simple as possible i am going to give a definition of each plan and explain the terminology within the terminology, because we all know that with any plan, there are maximum out of pocket charges, or as i like to call them (out of pocket Surprises), co-insurance, deductibles, co-pays and other such terms which can confuse even the smartest person.
So let's get started, and remember i am keeping it simple, this is just an overview of the different plans, i will get into each plan more thoroughly through future postings.
Traditional Major MEDICAL PLANS- In a major medical plan the insured (you) is responsible for paying a deductible before the insurance plan pays any benefits. Then the insurance company pays 70, 80 or 90% and the insured (you) would be responsible for the remaining 10,20 or 30%
Deductibles- The amount you are responsible to pay before the insurance company starts to pay their share.
HMO's Also known as a Health Mantenance Organization, is a type of insurance plan that focuses on the long term care of its insured and is normally less expensive than a Major Medical Plan. Each insured has a Primary Care Physcian, who is responsible for providing preventative care and coordinating care for the insured. If additional specialists or hospitalization is neccessary. You the insured may need to get prior authorization, you may need a referral from your primary care physcian.
This keeps the costs down, You would have co-pays, and you may have to stay in network.
The HMO is known as the co-pay plan and the majority of HMO's only cover in-network doctors and hospitals, and you are required to get a referral before seeing a specialist or your claim can be denied.
PPO Plans- Preferred Provider Organizations, is similar to an HMO, as there is a network of physcians and hospitals, but unlike an HMO, an insured (YOU) is not limited to only in network physcians and hospitals and can go out of network and see who they would choose to see. Keep in mind though, if you stay in network, your copays and deductibles will be less for in network services.
In addition, network physcians determine reasonable charges, therefore is an out-of-network physcian charges more for services, the insurance company will still pay only 80% of the in-network charges any additional fees the insured would be responsible. In that scenario the insured will often pay higher fees for out-of network services.
Most people prefer the freedom to choose their own doctors and not be limited to one network.
POS Plans- Point of Service Plans
Is considered to be a combination of a PPO and an HMO. The insured (you) chooses a Primary Care Physcian and all health care should start with the patient consulting the physcian. The doctor authorized a referral to see a specialist, in or out-of-network. Keep in mind that with an HMO, the specialist must be in network in order for the service to be covered.
If a patient chooses to see a specialist without a referral, the insurance company may choose not to pay for the services. A POS plan is also considered to be a managed health care plan, but the insured has the capability of having more options than the standard HMO Plan.
Health Savings Accounts - HSA's
A health Savings Account is an alternative to traditional health insurance, it is a savings product designed to offer a different way for consumers like yourself to pay for their own healthcare. HSA's enable you to pay for current health expenses and to save for future qualified medical and retiree health expenses on a tax-free basis.
A Health Savings Account combines a high deductible health insurance with a tax-favored savings account. Money in the savings account helps pay the deductible. Once the deductible is met, the insurance company starts to pay. Money left in the savings account earns interest and is yours to keep.
An HSA account can increase your health insurance buying power by:
- Typically lowering your health insurance premiums, but still providing quality care
- Regaining more control of your health care dollars
- Paying your out-of-pocket health care expenses with tax advantaged savings
- Spending your HSA Savings tax free to help pay your health insurance deductible for qualified medical expenses including prescriptionsm vision or dental care.
- Providing one simple calendar year deductible per family
- Tax-deductible- contributions to the Health Savings account are 100% deductible up to the legal limit just like an IRA ( Individual Retirement Acccount)
- Tax-Deferred interest earnings accumulate tax-deferred and if used to pay qualified medical expenses are tax-free
- HSA money is yours to keep, Unlike a Flexible Spending Account often provided by an employer, unused money in Your health Savings Account, isn't forfeited at the end of the year, it continues to grow tax-deferred.
To get the benefits of an HSA, the law requires that the savings account be combined with a high deductible health insurance plan. High deductible health insurance plans cost less than the traditional $250-$500 deductible coverage, because the insurance company doesn't have to process and pay claims for routine, low-dollar medical care.
The Co-pay Plans
Co-pay plans provide traditional insurance benefits for people who need routine health care. Co-pay plans are similar to traditional coinsurance offered by an employer that includes a copayment amount for out-of-pocket medical expenses. If you are looking for a plan that offers co-pay benefits, preventative care, and prescription drugs, then the copay plan is best suited for you.
When you use a preferred network doctor for an office visit, carriers will pay 100% for history and exam fees after a specific co-pay amount. Office expenses outside your network will not be eligible for co-pay benefits typically.
additional features include:
- Prescription Drug card benefits
- Comprehensive coverage for inpatient and outpatient medical expenses
Short term Health Insurance
Life can change quickly and you may need the protection of a short term health insurance plan. Short term medical insurance products can be an alternative to Cobra health insurance and can provide temporary health insurance for individuals who may have:
- Lost coverage through a recent job or life changes
- Recently graduated and are no longer covered by parent's plan
- A job as a seasonal worker
- Begun enjoying early retirement and are waiting for medicare to kick in.
- Recently completed Cobra coverage
Guaranteed Issue Plans-
These plans are a nickel a dozen, there a whole lot of these plans out there, and most people are very confused about them. the majority of Guaranteed issue plans are not traditional insurance plans, what they are in actuality are Hospital idemnity plans with or without additional medical benefits.
These plans do not have medical questions that need to be answered, there is no underwriting, the enrollment into these plans is usually one page or less. Whenever you use these plans, the benefits are paid directly to you. Some people call these reimbursement plans.
If you can't afford traditional health insurance, or have been turned down for health insurance due to pre0-existing conditions, these plans are good alternatives.
Terminology that you should know
Benefit Period- a specified period of time during which benefits for covered services must be used. Example, a calendar year ( january-december) or a contract year ( 12 consecutive months following your effective date of enrollment).
Benefit Period Maximum- The total amount your insurance plan will pay for covered medical expenses during each benefit period.
Calendar Year
The 12-month period begining on January 1st and ending December 31st.
Coinsurance - A cost- sharing requirement under which you are responsible for paying a certain percentage of the covered medical expenses, after you meet your deductible (if applicable).
example
you have a 100,000 hospital bill and a plan with a $5000.00 deductible and 80/20 co insurance
100,000 hospital bill
5,000 deductible
95,000 balanace
You would pay 20% of the 95,000 with a maximum out of pocket that varies from carrier to carrier and the carrier would pay 80% , and then 100% above your maximum out of pocket.
There would be additional costs over and above this if you use providers who are out of the carrier's network they provide. This is very important issue for most people. You should always speak to an agent or broker concerning each carriers plan design.
Contract Year - The period of 12 consecutive months following the effective date of your agreement and each subsequent 12-month period that the agreement is in effect.
Co-payment - a cost sharing requirement under which you are responsible for paying a set dollar amount for covered medical expenses. Some plans require you to meet your deductible first and others don't.
Deductible- amount you must pay out of your own pocket before the plan begins to pay for any covered services.
Effective Date - The date, as shown in your carrier records, on which ytour health care coverage begins.
Guaranteed Issue- Plans that accept all applicants without regard to the applicants state of health.
Medically Underwritten - Plans that base acceptance for enrollment on your health status, determined by the answers you give on a medical questionnaire.
Health Savings Account (HSA) A savings account for out-of-pocket medical expenses in which contributions and interest earned are tax-exempt and withdrawals are tax-free if funds are used for eligible medical expenses. An HSA is used in conjunction with a high deductible health plan.
High Deductible Health Plan ( HDHP) - a health plan that offers substantial savings in monthly premiums in conjunction with higher than usual deductible levels. When you enroll in a qualified HDHP, you may be able to take advantage of the tax savings offered by a health Savings Account (HSA).
Health Maintenance Organization (HMO) - a health care program that provides coverage only for those eligible services received within the insurance carrier's provider network. There is no reimbursement to you if you use a doctor or hospital that does not participate in the carrier's network ( unless it is an emergency).
Lifetime Maximum- The total amount your insurance plan will pay for covered medical expenses while you are enrolled in your plan. With some carriers they also limit how much of the lifetime maximum you can use per year.
Networks- These are companies that have negotiated lower rates with providers such as doctors, hospitals, outpatient care facilities, and other health care providers. Some insurance carriers have their own network contracts with these providers. Every insurance carrier will either use their own network or they will buy the services of an independent network company to keep their costs lower when you utilize the plan.
These discounted rates get passed down to you if you buy a plan where you're deductible needs to be met first. When calling a provider to check whether or not they participate with your insurance carrier, always tell them what network your carrier uses. It is not unusual for a provider not to recognize your carrier but will recognize the network provider.
Non-participating Providers - Providers that do not have agreements with the network your carrier is providing to you. These providers may "balance Bill" you for any differences between the carriers payment amount and the provider's actual charges. Insurance carriers who pay UCC verse RCC give you more protection against and financial surprises when you utilize your plan.
UCC- Usual, Customary Charges
RCC- Reasonable, Customary Charges
Out-Of-Pocket Maximum -The maximum amount you will pay out of your own pocket for covered medical expenses during a given benefit period. Normally this requires that you stay within the network your carrier provides. Some companies have limits even if you are out of the network while others don't.
Participating Providers- Providers that have agreements with networks to accept carriers payment amounts as payment-in-full for covered services ( after any applicable deductible, co-payments or co-insurance).
Pre-Existing Condition - a condition for which medical advice or treatment was recommended by a physcian or other medical provider within a carrier specified time frame immediately before your effective date.
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