Table of Contents

Traditional vs. Managed Care Coverage
Types of Major Medical Coverage
Other Health Related Policies
Health Savings Accounts
Continuation of Coverage
HIPPA
Things to Consider
Questions and Answers About Premiums
Consumer Tips
Filing Claims
Medical Information Bureau
Medicare
Medicaid
Glossary

Nobody plans on getting sick or injured, but life is full of unexpected events that force us to seek medical care. These include everything from a common cold to a more prolonged illness or injury. When these situations arise, your best financial defense is to have adequate health insurance.

Health insurance can help protect your assets and pay medical expenses, but selecting the policy to best meet your needs can be challenging. This guide explains the various types of policies that are available, offers tips on choosing a policy and provides definitions for the numerous health insurance terms you may encounter. If you have any questions after reading this guide, please call the Helpline toll-free at 1-800-335-0639.

Evolution

Health care in America is changing rapidly. Twenty-five years ago, most people in the United States had indemnity insurance coverage. A person with indemnity insurance could go to any doctor, hospital, or other provider (which would bill for each service given), and the insurance and the patient would each pay part of the bill.

But today, more than half of all Americans who have health insurance are enrolled in some kind of managed care plan, an organized way of both providing services and paying for them. Different types of managed care plans work differently and include preferred provider organizations (PPOs), health maintenance organizations (HMOs), and point-of-service (POS) plans.

You've probably heard these terms before. But what do they mean, and what are the differences between them? And what do these differences mean to you?

Traditional Versus Managed Care

Your first health insurance choice may be to decide between traditional health insurance and a managed-care option. With traditional health insurance, you – the policyholder – select a health care provider, such as a doctor or hospital. You may have to pay for services when rendered and then submit the bill to the insurance company for reimbursement of the portion it agreed to pay under the policy terms. Frequently, the provider will submit the bill directly to the insurer and await payment.

The managed-care system combines the delivery and financing of health care services. This limits your choice of doctors and hospitals. In return for this limited choice, however, you usually pay less for medical care (i.e., doctor visits, prescriptions, surgery and other covered benefits) than you would with traditional health insurance. The managed-care network controls health care services.

Types of Managed Care

Health Maintenance Organizations (HMOs)

HMO members pay a monthly fixed dollar amount (similar to an insurance premium), which gives them access to a wide range of health care services. In many cases, members also pay a predetermined amount, or co-payment, for each doctor or emergency room visit and for prescription drugs, rather than paying the provider in full and obtaining a portion of the reimbursement later. Recent legislative and regulatory changes have provided HMOs with the opportunity to offer plans with deductibles and coinsurance similar to PPOs (discussed below). HMO members often have little or no paperwork to complete due to the elimination of reimbursement. They must use the HMO’s network of providers, which may include the doctors, pharmacies and hospitals under contract with that particular HMO. You may obtain the free publication Health Maintenance Organizations:

Exclusive Provider Organizations (EPOs)

In an EPO arrangement, an insurance company contracts with hospitals or specific providers. Insured members must use the contracted hospitals or providers to receive benefits by these plans.

Preferred Provider Organizations (PPOs)

A PPO offers another kind of provider network to meet the health care needs of consumers. A traditional insurance carrier provides the health benefits. An insurer contracts with a group of health care providers to control the cost of providing benefits to consumers. These providers charge lower-than-usual fees because they require prompt payment and serve a greater number of patients. Consumers usually choose who will provide their health services, but pay less in coinsurance with a preferred provider than with a non-preferred provider.

Point-of-Service Plans (POS)

These plans may be called by a variety of names and have various features. They combine some aspects of traditional medical expense insurance plans and other aspects of HMOs and PPOs. In a POS plan, insured members may choose, at the point of service, whether to receive care from a physician within the plan’s network or to go out of the network for services. The POS plan provides less coverage for health care expenses provided outside the network than for expenses incurred within the network. Also, the POS plan will usually require you to pay deductibles and coinsurance costs for medical care received out of network.

Types of Traditional Care

Basic Medical Insurance (hospital / medical / surgical)

Hospital insurance usually pays a portion of your room and board. It may also pay some expenses for other hospital services, such as operating room use, laboratory tests and X-rays. Medical/surgical insurance helps pay for surgical and related costs (either in the hospital or doctor’s office), and may pay for anesthesiology. It may also pay doctor fees for medical visits when you receive hospital care other than surgery. Payments for surgical expenses are usually fixed amounts based on a surgical fee schedule. Insurance companies use fee schedules to determine the average cost of a procedure according to usual, customary and reasonable charges.

• Usual refers to the fee a doctor most frequently charges for a procedure.
• Customary involves the range of usual fees charged by doctors of the same specialty in a given geographic area for
  a specific procedure.
• Reasonable applies to a fee that differs from the “usual or customary” charges because of unusual circumstances. The procedure may involve medical complications that require additional time, skill and expertise. This provision limits the amount the insurance company will pay under your policy. If possible, check what your insurer will pay prior to the delivery of medical services subject to a usual, customary or reasonable rate.

Basic medical insurance policies offer consumers differing benefits for room and board, physician, surgical and miscellaneous expenses. You should carefully check to see if policies offer equal benefits when comparing premium rates.

Major medical insurance

These policies provide protection against the high costs of hospitalization, injuries and serious or ongoing illnesses. Other possible coverage's include the costs of blood transfusions, drugs and out-of-hospital costs, such as doctor visits. Most group health policies fall under the category of major medical policies. This category also includes the basic and standard plans issued under small group health access coverage.

Major medical policies cost extra and provide more benefits than basic policies. A major medical policy normally pays 80 percent of covered expenses, after you pay the deductible. Insurance companies use fee schedules to determine the average cost of a procedure; however, this cost may differ from the actual charge you receive. Many PPO plans stipulate that the provider may not charge for the actual cost in excess of the usual and customary amount.

Maximum out-of-pocket limits restrict the amount of coinsurance you pay. Not all policies include such limits, but those that do pay 100 percent of remaining covered expenses after you pay a stated amount of coinsurance.

Types of Major Medical Coverage

Group Plans (Get a Quote)

Fulfilling your insurance needs may prove relatively simple if your employer offers a group plan or a choice of plans. Group plans cover several people or groups under one policy. You will receive a certificate that acts as your policy when you obtain insurance through a group plan. Most group policies are suitable for the average person and may include provisions to cover family members.

Businesses with one to 50 employees have access to guaranteed-issue group plans, often referred to as small group health coverage. Guaranteed-issue coverage for a one-life group (a self-employed individual with no eligible employees) is only available during the month of August each year, with the policy being effective on October 1. These plans are available to small-business employers regardless of the health claims experience of an employee group or the health status of an employee. Insurance companies and HMOs that offer small group coverage must offer employers the option of purchasing a basic or standard plan. Most insurers or HMOs offer other health-benefit plans in addition to the basic and standard plans.

Individual Plans (Get a Quote)

Individual plans cover one person or all members of a family under one policy. Usually, people buy individual plans because they lack access to employer-based group policies or want to supplement these policies. Others use individual health policies during periods of unemployment when they lack coverage under group policies, or because they want to supplement Medicare benefits. If you buy an individual policy, you may take 10 days from the date you receive the policy to decide whether to keep or cancel it. For a full refund, you must return the policy to the company within the allowed time. If you reject the policy, you should return it by registered or certified mail. This may help you to avoid a potential dispute with a particular insurer.

Out-of-State Association-Based Coverage

An insurance company that markets health coverage to members of an association must be licensed by your state to sell such coverage to members who are state residents. However, if the association is located in a state other than your's, the coverage offered to members will likely be governed by the laws of that state–not yours. This means that many of your state consumer protection laws will not apply to this coverage–most notably rate approval requirements. While this “out-of-state association” type of coverage may appear affordable in the beginning, the absence of laws protecting the consumer from renewal rate abuses may become more apparent in future years.

This would become an issue should you develop a chronic health condition and are unable to medically qualify again for a more affordable policy. The decision to purchase out-of-state association coverage must be carefully considered in light of personal circumstances, with an emphasis on how long one anticipates needing the coverage and other options for coverage should it become unaffordable. In general, the longer one will need the coverage, the more important it becomes to consider coverage that is governed by all of your states consumer protections laws–not just some of them.

In addition to major medical plans, there are self-insured plans.

Traditional health insurance and managed-care plans form major parts of the American health care system. However, employers may select an alternative to cover health expenses and meet employees’ needs. This is known as a single-employer plan.

Single-employer plans

These plans fall under the guidelines of the federal Employee Retirement Income Security Act (ERISA). Employers establish these plans to provide health care and/or other employment benefits to employees, their families and dependents. An insurance carrier may fully insure a plan of this type or the employer may opt for self-insurance.

Employers participating in a self-insured plan assume the financial risks involved, rather than transferring this risk to an insurance carrier. The employer pays for claims filed by employees covered by the plan. Your employer might hire an insurance company to administer the plan, but this company does not take responsibility for paying claims.
Your state insurance department might not regulate self-insured, single-employer plans. In addition, the Guaranty Fund, which pays losses to policyholders when certain insurance companies become insolvent, does not cover such plans.

An insurance company’s name or logo may appear on the forms and paperwork you receive from your single-employer, but this should not fool you. Many of these plans hire an insurance company to handle paperwork. The insurance company acts as a third-party administrator, but does not assume any legal obligation to pay claims.

You should determine whether your coverage comes from a self-insured plan. An insurance company may appear to underwrite a plan without actually doing so. You should also check the history of the group offering the plan, and talk to current members to see if they have experienced any trouble getting claims paid.

Facts to consider

Group and individual health insurance plans usually offer coverage for family members. Family policies generally pay benefits for your spouse and your dependent children up to the age specified in the policy. However, your insurance company cannot terminate coverage for dependent children who lack other means of support due to mental or physical handicaps. Both group and individual plans may include several kinds of coverage, such as “hospital,” “medical/surgical” and “major medical.”

Supplemental Health Insurance

These policies provide coverage beyond, or in addition to, what your basic policy provides. You should use these policies as supplements, rather than substitutes, for basic medical insurance. Some policies include elimination periods, which means companies will pay benefits only after you stay in the hospital for a specified number of days.

Hospital confinement indemnity insurance

These policies pay a fixed amount or indemnity for each day, week or month you stay in a hospital. Such policies pay a flat amount for benefits.

Disability income insurance

These policies pay a weekly or monthly income for a specific period if you suffer a disability and cannot continue or obtain work. The disability may involve sickness, injury or a combination of the two. Most disability insurance plans coordinate with Social Security benefits and workers’ compensation to eliminate duplication of coverage.

You may select a disability policy that includes an elimination period, or length of time that you must wait after a covered illness begins, before receiving benefits. The longer the elimination period, the lower your premium. Premiums may also vary depending upon your occupation (and the risks involved) and your age. For example, a high-rise construction worker would likely pay higher premiums than a florist.

When buying a disability policy, you should find out the company’s definition of a disability and the requirements that must be met. Individual and group disability income policies must provide coverage for a policyholder or eligible dependent who becomes disabled. This coverage applies during the first 12 months of the disability, but only if the person can no longer perform material and substantial duties of his or her occupation. After the first 12 months, the company may base the continuance of benefits on the person’s ability to perform any work for which he or she is reasonably trained.

An insurance company paying for a disability claim may require the policyholder to provide a written doctor’s report. The frequency of this requirement depends upon the particular policy. For example, a given insurer may require such medical updates every month. In addition, the insurer may monitor certain public activities by policyholders who file claims. Insurers may do so to fight fraud and keep insurance costs down.

Accident insurance

These policies cover death, disability, hospital and medical care resulting from an accident. A common variation called “accidental death insurance” can pay additional benefits for death due to motor vehicle or at-home accidents.

Limited benefit insurance

These policies cover certain expenses from specifically named illnesses, injuries or circumstances. For example, cancer policies pay benefits for the actual treatment of cancer. Some also pay benefits for conditions or diseases caused or aggravated by cancer or its treatment.

Long-term care insurance

Long-term care encompasses a wide range of medical, personal and social services. A person may need this care if they suffer from prolonged illnesses, disabilities or cognitive impairment. Private insurance companies offer individual or group long-term care insurance policies that provide benefits for a variety of services not covered by your regular health insurance, or by Medicare or Medicare supplement insurance.

Home health care policy

This type of policy covers services prescribed by a physician and from a Medicare-certified or state-licensed home health care service. The care must help with activities of daily living or the supervision or protection of a patient with cognitive impairment (such as Alzheimer’s disease or senility). Some policies offering nursing home coverage automatically offer home health care as well. Some companies offer home health care as an option or rider to a long-term care policy. A few companies offer policies covering only home health care. You may obtain more information about policy options from your agent.

Nursing home care policy

This limited-benefit insurance policy offers an alternative for some people and covers either one level or several levels of care. The levels of care include custodial, intermediate and skilled (defined in the Glossary). Cognitive impairment or the inability to perform one or more of the activities of daily living will activate the benefit trigger of this care.

Health Savings Accounts

Health Savings Accounts (HSAs) are new tax-free savings plans that Floridians can take advantage of to pay for qualified medical expenses. This program allows consumers to deposit pre-tax dollars into their HSA up to the level of their deductible. HSAs must be used in conjunction with a high-deductible health plan. To qualify, the health plan must have a minimum deductible of $1,000 (up to $2,650) for an individual policy and $2,000 (up to $5,150) for a family policy. The insurance premium is paid for outside of the HSA. For a list of companies offering qualifying insurance policies, please call us at 1-800-335-0639 or Click Here for a Quote.  For more information on HSAs, Click Here. 

Continuation of Coverage

Cobra

The Federal Consolidated Omnibus Budget Reconciliation Act (COBRA) allows retiring employees, or those who lose coverage due to quitting a job or reduced work hours, to continue group coverage for a limited period of time. This also applies to their dependents who lose coverage because of divorce or legal separation; death of the covered employee; the covered employee qualifying for Medicare; or a loss of dependent status under the health plan’s provisions. COBRA applies only to employers with 20 or more employees.

If you qualify for COBRA benefits, your health-plan administrator must give you a notice stating your right to choose to continue benefits provided by the plan. You then have 60 days to accept coverage or lose all rights to the benefits. Once you select COBRA coverage, you may have to pay 100 percent of the total insurance cost, plus a two percent processing fee.

Mini-COBRA (Florida residents)

Florida’s mini-COBRA law provides similar continuation of coverage protection for employees who work for employers with fewer than 20 employees.

Note: Under Florida’s mini-COBRA law, the employee must notify the insurer within 63 days of losing group eligibility that he or she is eligible to continue coverage.

Qualifying for COBRA and Mini-COBRA

Continuation of coverage runs from a minimum of 18 months to a maximum of 36 months, depending upon the individual situation. The coverage may continue for an additional 11 months for an insured’s disability that occurs during a qualifying event such as termination (except for gross misconduct) or a reduction in work hours for the employee; however, it cannot exceed the limit of 36 months. Other qualifying events may include:

·         a beneficiary loses coverage due to the employee’s death;

·         a divorce or legal separation of the employee and a spouse;

·         the employee’s qualification for Medicare; and

·         a dependent child’s loss of status under the health plan’s provisions.

Health Insurance Portability and Accountability Act (HIPPAA)

Federal provisions referred to as the Health Insurance Portability and Accountability Act, govern many important health insurance continuation situations. Whenever you have a question concerning your health care coverage circumstances when your coverage is terminated, you lose health care benefits when your employment or COBRA ends, or your coverage changes because of a change in carriers or a change in your job, you may find yourself in a situation where HIPAA protections apply.

If you have any questions regarding your health insurance, you may call the us toll-free at 1-800-335-0639 to discuss your options under HIPAA and state law.

Portability

One of the most important HIPAA protections involves credit for prior coverage, often referred to as portability. HIPAA requires that time spent under previous coverage reduces any waiting period for a pre-existing condition under a new group plan you join. The law also limits these waiting periods to 12 months for a new employee joining the plan or 18 months if an employee decides to join the plan at a later date. (However, a pregnant woman who changes jobs and joins a new plan with two to 50 employees does not have to fulfill a waiting period before the health plan must pay for health care services associated with the pregnancy.)

Your insurance company will issue a “certificate of previous coverage,” which is your proof of prior coverage and is required to be issued to you when your coverage terminates. This certificate will include a statement of how long you and any dependents were insured. It will also explain to your new employer or company the range of benefits and coverage you had under that plan or policy.

You may have had health plan benefits for the most recent 12 months from either a group plan or an individual insurance policy. In either case, your previous coverage will generally reduce any waiting period for a pre-existing condition if you apply for a new group plan within 63 days.

Please note: The waiting period a new employee experiences before they are eligible for benefits is not included in the calculation of the 63 days.

"Guaranteed-issue" individual health insurance policies

Normally, people seeking individual medical coverage submit to medical underwriting to determine if they are sufficiently healthy to qualify for coverage. However, under certain circumstances, individuals may qualify for guaranteed-issue health policies by virtue of HIPAA and state law, meaning that the coverage must be issued regardless of the applicant’s health status.

Who qualifies for a "guaranteed-issue" policy?

There are important requirements that determine whether you qualify for a guaranteed-issue, individual health insurance policy:

• You previously held membership under an employer group health, governmental or church plan, and no longer qualify for that plan or any other group plan;

• You exhausted any available COBRA or similar continuation of coverage periods;

• You have had 18 months of coverage with no “break in coverage” for a period greater than 63 days in which you lacked group or COBRA insurance; or

• You were issued individual medical coverage because your insurer withdrew from your area and you lost coverage.

Coverage for a pre-existing condition

The policy may not completely exclude coverage for pre-existing conditions for you, your spouse or dependents by issuing a rider to the policy.

Coverage for a newborn or newly adopted child

If your child was born or adopted within the last 18 months, the child does not have to meet a “prior coverage” requirement. The child qualifies for benefits as soon as the policy begins.

Things to Consider when Comparing Health Care Options

Choosing a health care plan is an important decision. A health care plan provides financial protection from the costs of an unforeseen event or condition. You should make sure that the company that you are purchasing coverage from, as well as the agent, are licensed. Your financial needs and your ability to absorb routine costs will affect the type of policy you purchase. Purchasing a policy that provides for first dollar protection is very expensive. You need to evaluate your financial needs and decide what level of costs you are able to handle and for what level of costs you need to purchase financial protection. The greater the cost sharing between you and the company, the lower the premium cost will be to you. If you purchase coverage at a lower premium, but the policy will not pay costs until a certain dollar value is reached, you need to be able to meet this cost responsibility. Consider the following features when comparing health care options.