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Frequently Asked... |
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Phone: (480)
219-4270
8
am - 5 pm MST
Email: click here for e-mail
FAQ's and
Glossary - the complete list follows:
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Answers to "Frequently Asked..."
- Try
switching to a PPO, instead of an HMO (especially cost saving for women
& children)
- Try
lowering your benefits, such as:
- A
larger deductible
- Higher
copays
- An
80% plan, instead of 90%, especially if the “Out-of-Pocket” is the
same
- A
“catastrophic” plan
- An
HSA (Health Savings Account),
where you take a high deductible health plan, then put the premium savings into a cash
fund that is tax deductible. Click here for information &
premium quotes for HSA's.
- For
Individual / Family plans only - Try
switching Insurance Companies, even if you have to split family members into
different plans to maximize the savings. You will find a premium
breakdown by family member on all the plans we quote. Click
here for
information & premium quotes.
- For
Group plans only - consider alternative funding, like Consumer-Driven Health
Plans (CDHP's), Partially Self-Funding, etc. Click
here for information and premium quotes
for Group Plans.
- For
Group plans only - consider tax-favored plans, like Health Reimbursement
Accounts (HRA's), Flexible Spending Accounts, Section 125 Premium Only Plans
(Tax-Free Premium Plans), etc. Click here for
Information & quotes.
Back to top
- The
premium is often less on an Individual/Family plan than a Group plan if:
- You
are young
- You
are not a female in child-bearing ages, or you don’t need maternity
coverage
- Your
Employer does not pay much of the premium for your family
- You
have 2 or less children
to cover (You may even cover your children alone on an Individual / Family
plan, without covering the parents).
- Click
here to find the rates for your family
Back to top
- You
can look at the Provider Networks on-line. Click here to begin.
- You
may call your Doctor’s office to ask if he/she is in the Network.
Be sure to specify if it is an HMO or PPO, or which network.
Back to top
I want Maternity coverage
See the definition of "Maternity
Coverage" below
Back to top
- Employer Group Plan - You will probably
have a "new-hire waiting period", before you become eligible for
the Group plan through your new Employer. You should consider a
Short-Term plan (or another option below) to fill the gap, during your
"new-hire waiting period". If the cost is high for your new
Employer's Group plan (or if your new Employer does not offer health
insurance), consider one of the following options.
- Short-Term Temporary Plan - A
“Short-Term” Temporary plan fills the gap between plans, (for instance,
while you are waiting for your new Employer's Group plan, or while you are
in the application process for an Individual/Family plan). Click here
for more information about Short-Term plans, including some cautions for
those individuals with pre-existing conditions, and rights to COBRA or
Guaranteed Issue.
- Individual/Family Plan - Even if your
new job provides Group health insurance, you should consider an
Individual/Family plan. This may be the least expensive choice.
However, it is medically underwritten (i.e. you will be asked health
questions), and the application process will take some time. Click
here for premium quotes and plan comparisons.
- COBRA - You may be offered COBRA
continuation of coverage through your prior Employer. It may be more
expensive than an Individual / Family plan, but it comes with more rights.
Deadlines apply, so be sure to read your COBRA letter carefully.
- Spouse's Employer's Group plan - Loss
of your coverage may be considered a "qualifying event", which
allows you to join your Spouse's Employer's Group plan, even if it is not
open enrollment.
- Retirement or Conversion Plans -
Retirement plans from your Employer can be great, but we rarely recommend
Conversion plans, unless there is no other valid option.
- HIPAA Portability (Guaranteed Issue) Plans
- These plans are especially important for those who have health conditions,
which would disqualify them from obtaining another plan. They are
expensive, but they are "Guaranteed Issue", which means you cannot
be denied coverage, provided that you meet the qualifications. More
information is provided in the section above, concerning those with medical
conditions.
Caution: Do not discontinue any
coverage, or bypass any rights to coverage options. If you have a medical
condition, click here for a Guide, meant for those who are Uninsured and/or
having difficulty obtaining health insurance.
Back to
top
If you have a medical condition, there are 2 main
issues to be concerned about:
Question # 1 - Can I obtain Health Insurance?
Click here for a Guide, meant for those who are Uninsured and/or having
difficulty obtaining health insurance.
Question # 2 - What is the Pre-Existing
Conditions Waiting Period? Click here for more information about
Pre-Existing Conditions clauses. Also, we fully disclose the Pre-Existing
Conditions clause for every insurance plan. You will find it on the
Benefit Comparisons (Benefits-at-a-Glance) for the Individual / Family Plans,
and on the brochures, certificates of coverage, and policies for every
plan. Please be sure to call us with any questions or concerns you may
have.
Back to top
I'm
having trouble getting health insurance, and I'm Uninsured. Do you have a
guide to help me? Yes. Click
here for a Guide meant to help those who Uninsured and/or who are having
difficulty obtaining healthcare
coverage because:
- They have a medical condition and have been
turned down for health insurance
- They cannot afford the premium because:
- Their premium has been rated-up due to a
medical condition
- They are in a low-income category
- They have just lost their health insurance
(usually due to a change in
jobs) Back to top
- You
may discuss your situation with a knowledgeable person at any time.
If we cannot resolve the situation for you, we will offer suggestions
and referrals, to help you meet your needs.
- HMO’s
(Health Maintenance Organizations)
- Positive
- HMO’s
may have better benefits, such as:
- MATERNITY
COVERAGE on Individual / Family Plans (On Employer Group Plans,
Maternity coverage is almost always included)
- Copays
for most services, including hospitalization
- No
deductibles (on some plans)
- 100%
Co-Insurance (on some plans)
- Expanded
“Well-Care” coverage
- Negative
- HMO’s
restrict your access to the Provider of your choice
- You
must select a Primary Care Physician, who refers you to any Specialists
that you may need
- They
have a smaller list of Providers in the Network
- You
are not covered Out-of-Network, unless it’s an emergency
- PPO’s
(Preferred Provider Organizations)
- Positive
- PPO's usually have
lower premiums, particularly for women & children
- Positive
- PPO’s
have greater access to the Provider of your choice
- You
do NOT need to select a Primary Care Physician
- You
may self-refer to Specialists
- You
have a larger list of Providers in the Network
- Often,
there is a National network, in case you are traveling
- You
are covered Out-of-Network, however, your Deductibles and Co-Insurance
Percentages will be greater for Out-of-Network charges.
- Negative
- PPO's have lesser benefits, such as
- On
Individual/Family PPO's there are no Maternity benefits except complications of pregnancy.
(On
Employer Group Plans, Maternity coverage is almost always included.)
- Deductibles
- Co-Insurance
Percentages of 90% or 80% (after the deductible is met)
- Some
plans limit the “Well-Care” coverage
Other plan designs that are a
"marriage" between an HMO & a PPO are:
Back to top
Health Insurance policies protect you from the
high cost of medical care. They pay for your covered medical
expenses. But they do not pay 100%. They require you to pay for a
portion. The portion YOU PAY falls into 3 categories:
- Copay - a modest fee you pay (such as
$15 for an Office Visit to the Doctor). Copays are often required for
services such as Dr. Office Visits, Prescriptions, Urgent Care Visits, and
other common Outpatient expenses. On a few plans (like HMO's), there
is a Copay for Hospitalization. After your copay is met, the Insurance
Company pays the rest of the charge. Almost always, the Deductible &
Co-Insurance are NOT required when the Copay is required.
Deductible & Co-Insurance - for
larger major medical expenses (such as hospitalization, surgery, MRI's, CAT Scans, etc.),
you may have to pay the Deductible & Co-Insurance.
- The
Deductible comes first. You pay this part of your bill before
the Co-Insurance percentage begins.
- The
Co-Insurance percentage comes next. As an example, you might
choose a plan that pays 80% Co-Insurance. That means you pay 20%.
- The Out-of-Pocket maximum stops
your Co-Insurance percentage. At this point, the Insurance
Company pays 100% of the remainder of the covered expenses, for the
rest of the Calendar Year. This protects you against
catastrophic losses on a very large claim.
Back
to top
Those who need coverage outside of Arizona
usually fall into four categories:
- Snowbirds - those who live in Arizona
part of the year, but reside elsewhere for several months of the year.
We have plans with National Networks that should work well for you.
Please call us for guidance about plan choices, and about any residency
requirements.
- Other State Residency - residents of another
State. We can place coverage in all 50 States, and many foreign
nations. Please call us for more information.
- Multi-Location Groups - Groups
who have Employees who live in another State, or a Foreign Nation. We
have plans with National Networks, and even plans that will cover Employees
in Foreign Nations. Please call for details.
- Travelers - those who travel inside the
US, and to foreign nations
- Those who travel inside the US will probably need to select a plan with a National
Network or a Travel Network with In-Network Providers across
America. There are
many plans that meet this criteria. Please call us for
guidance.
- If you are traveling abroad, you may also
wish to purchase a separate Travel Health Plan.
- If you are a foreign resident, traveling
in or residing in the United States, you may wish to purchase a Travel
Health Plan, or call us for residency requirements for a traditional
policy.
Back
to top
No. You pay no fees to us. We are
paid a commission by the Insurance Companies. This commission is already
built-in to the premium for your plan. That means that you would be charged the same premium if you contacted the
Insurance Company directly, as you are charged if you use an Agency like
ours. When you use the services of an Agency, you get the added value of
our Customer Service & expertise, without additional charges.
Back
to top
- First,
we scrutinize every plan, and every Insurance Company, before we present
them to you. We look for the
major issues, and also for hidden issues that Consumers rarely know to look
for. We don’t add Insurance
Companies quickly, and rarely find a reason to delete any, after they have
meet our criteria to be presented to you.
The list of issues we consider is large. Here is a brief summary:
- Stability
of the Insurance Company
- How
well rated is the Insurance Company?
We look for high ratings from well-known traditional services
that rate Insurance Companies and Health Plans, such as the A.M. Best
Company, Standard & Poor’s, Duff & Phelps, etc.
- How
long have they been in business? We
look for longevity.
- How
long have they done health insurance business in Arizona, and have they
ever terminated their involvement in health insurance, only to return
with “new” plans? We
look for Insurance Companies that are committed to health insurance, and
committed to the Arizona marketplace.
We absolutely avoid Insurance Companies that have a history of
leaving and returning to the marketplace at will.
- Do
they have an abnormally large number of complaints at the State
Department of Insurance? We evaluate the complaint ratios
every year.
- Comparability
of their plans to those in the marketplace
- Are
the plan benefits “normal”, in comparison to other Insurance Companies' plans. We look
for broad coverage, with well-written benefits in each category.
- Are
the rate increases “normal”, in comparison to other Insurance
Companies' rate increases? We
carefully watch the rate increases, and make sure they are in line with
the competition in the same location.
- How
often does an Insurance Company raise rates? We won’t suggest plans when we see a history of rate
increases more often than annually.
- Can
you be "singled out" for rate increases or cancellation?
In Arizona (and most other States), you cannot be singled out for rate
increases or cancellations of health insurance, due to your
claims. Click
here for more information. However, we caution consumers to be wary of health plans,
sold by Insurers that are located in the Dominican Republic or other
sites overseas, which do not provide you with these protections.
- Are
there abnormal hidden “inside limitations”, such as very low dollar
limits per day for hospital stays, or low dollar limits for surgeries?
We will not recommend plans that are abnormal in their benefit
designs, especially if core benefits (like hospitalization
benefits) are
severely limited. This is unfair to the consumer.
- Service
and Claim Payment History
- Does
the Insurance Company pay their Doctors and Hospitals well? We review the
satisfaction ratios from the Providers, as well as the comparability of the Fee
Schedules.
- Do
Doctors and Hospitals have a history of terminating their contracts with
these Insurance Companies? When Providers remain contracted
with an Insurance Company for a long time, it is a sign that the
Insurance Company is paying their Providers well, and is giving good
Customer Service.
- Is
it a large Network of Doctors, or a small Network? A
large list often indicates that many Providers feel that the Insurance
Company pays their Providers well.
- Do
they pay their claims well? We listen to the Customer about
claims issues, and keep track of the volume of calls about claims
problems, and the types of problems encountered.
- How
many complaints do we receive about Claims, Customer Service, Billing,
etc? Are Clients happy with
their plans? This is one of the biggest indicators of good
Customer Service.
- Second,
we listen. When Clients,
Doctors, Hospitals, State Insurance Departments, Newspapers, Reviewers, or
others complain, we listen. If
the Insurance Company quickly corrects the problem, we consider that to be
flexibility and responsiveness on their part. If not, we will act to protect our Clients, and to make
sure they have quality plans.
- We’re
proud that the plans we present to you have been on our list for a long
time.
These Insurance Companies, and their plans have stood the test of
time, and the test of a vibrant competitive marketplace.
Back to top
Individual/Family plans do not come with as many
rights, therefore they can be less expensive.
For instance, under Group Health plans, a newly
hired Employee may be added to the Insurance plan, without health questions
being asked. Also, businesses with 2-50 Employees may not be denied Health
Insurance coverage by an Insurance Company. These are large risks that the
Insurance Company assumes, therefore Group plans are more expensive.
Not all types of Group plans are more
expensive. For instance, Group Disability plans are surprisingly
inexpensive. Group Dental plans are by far the most attractive, at good
rates.
Finally, Group Health plans are not necessarily
more expensive for certain people. Group plans usually "composite
rate", meaning they charge one rate, no matter what sex or age you are, and
no matter how many children are in your family. Therefore, Group plans are
usually less expensive for older-age individuals, families with many children,
women in child-bearing years, and infants. Individual / Family plans are
usually less expensive for the rest of the population. Click here for
information & premium quotes for Individual / Family health plans.
Back
to top
- Yes,
if it’s an Individual/Family plan. But you cannot do so on a Group plan from your Employer.
- To
find the premium rates for your children on the Individual / Family plans, click
here.
Back to top
Sure. The total premium is probably less
expensive.
But beware of possible problems, such as
Underwriting and Discrimination. If you have an Employee (or dependent)
who has a medical condition, it is far more difficult to qualify for an
Individual/Family plan than a Group plan. Underwriting requirements for
Individual/Family plans are restrictive. To attract & retain quality
Employees, you may want to offer them automatic enrollment in a Group plan,
rather than take chances with the Underwriting of an Individual/Family plan.
Also, be careful not to discriminate among Employees, by providing dissimilar
health plans to similar Employees.
Back
to top
No. Health Insurance
is regulated by the State so that an Insurance Company can not single you out
for cancellation or rate increases, due to your claims. When an Insurance
Company raises rates or cancels policies, they must do so for all similarly situated
policyholders (for instance, all policyholders in Arizona). For that
reason, we caution consumers to be wary of health plans sold by Insurers that
are located in the Dominican Republic, (or elsewhere overseas), because the laws
that protect you are not enforceable in those jurisdictions.
For Individual/Family plans, you will receive the
same rate increase as others who hold the same policy that you hold, and who are the same age &
gender, and who reside in
your location (such as your State or County).
For Small Business Group plans, other factors
apply. The actual RATE will only increase due to demographics (age, gender
& location of Employees), plus the basic rate increase given to all similar
policyholders. But Arizona allows Insurance Companies to raise the premium
an additional 15% if the claims for your Group were high. If your Group
policy is regulated by a State other than Arizona (for instance, if your Home
Office is in another State), you may be subject to the rate-increase rules of
that State.
There are other valid reasons why your Insurance
can be cancelled, such as if you don't pay the premiums or you move out of the
service area. For Groups, you must maintain specific requirements, like
minimum Participation requirements, minimum Group size (usually at least 2
employees), and minimum Employer Contribution levels.
Back
to top
Click here. To find the rate for you or
your family, we must know your zip code, ages, and gender of family
members. Fill out the convenient form, and your rate for each plan will be
inserted in the benefit comparison. Back
to top
Click here. You can get applications for
all the plans, available by mail, fax, printable pdf file, or
downloadable. Back to
top
Click here. Just complete the form, or call
us. To quote rates for Group Insurance, we must know some information
about the nature of business, location, gender & age of employees,
etc. Back
to top
Short-Term health insurance plans can cover the
gap in insurance, when you're between jobs, or waiting for another health plan
to begin. The coverage can be effective as soon as the day AFTER the your
completed application is sent to the Insurance Company. It can
continue month-to-month for as long as 12 months. Click here for more
information, brochures & applications.
Back
to top
We give you regular updates, by phone or by
e-mail, and we will keep you informed along the way. When you apply for
coverage, your application packet will include a brief summary of the
Underwriting process. Back
to top
Answers to "Types of Coverage"
and "Glossary"
Accidental Death & Dismemberment. This
benefit is often added to group life insurance plans, and it pays in case the
insured dies due to an accident, or suffers dismemberment. Back to top
Agents & Brokers are licensed by each State,
and are authorized by the Insurance Companies to represent them, sell policies,
and provide Customer Service. We are Independent Agents/Brokers,
which means we represent a number of Insurance Companies, not just one. We
receive a commission from the Insurance Company, not from you. There is no
difference in the plan, or the premium rates charged to clients who use
Agent/Brokers, than those who do not. When you use an Agency, like ours, you get the added value of
our Customer Service & Expertise, but you pay no extra costs.
Back to top
Arizona Health Care Cost Containment System. This is the
State of Arizona program that provides Healthcare to the indigent.
Back to top
Allowable Amount (or Fee Schedule)
See the definition for Fee
Schedule below Back to top
Large Employers usually self-fund their claims.
Now, smaller Employers can offer competitive benefits, with funding mechanisms
that save premium dollars, as well as taxes. Even Individual / Families
can enjoy these alternative funding arrangements through HSA's and CDHP's.
Most of these arrangements have one thing in
common - the concept of setting aside a cash account to pay for healthcare
expenses. To save premium, the business often chooses a high deductible
health plan, paired with a cash fund.
Click here for
more detailed information about the following types of Alternative Funding:
Back to top
A form one submits to the Insurance Company, in
order to enroll in, or apply for Insurance coverage. Back to top
A nominal fee (usually $15 or $20) which some
Insurance Companies charge to you, to process your application for an
Individual/Family plan (not required for Group plans). This fee is
non-refundable. As Agents, we
do not receive this fee, nor do we receive a commission based upon it.
Back to top
Groups who wish to Self-Fund (or Partially
Self-Fund) may contract with an Insurer or Third Party Administrator for
Administrative Services Only (to process
claims, design benefits, support a Network of Providers, and provide other
services necessary for their Custom-Designed Self-Funded Plan).
Back to top
Non-Network Providers are not under contract with the Insurance Company to discount their
bill. Therefore, a Non-Network Provider may "balance bill" you
for the actual charge, although the Insurance Company calculated its benefits
based on the discounted charge. (In-Network Providers are under
contract to discount their bill, and they may not "balance bill"
you.) Back to top
Basic Plan (or Catastrophic Plan)
See the definition for Catastrophic
Plan below Back to top
A brochure, or short summary that an Insurance
Company provides, which describes the benefits, limitations, and exclusions of a
policy. Sometimes referred to as a Benefit Grid. Even more detailed
explanations are in the Policy or Certificate or Coverage.
Back to top
Broker (or Agent)
See the definition for Agent
above Back to top
Cafeteria Plan (now known as a Flexible
Spending Account or FSA)
See the definition for Flexible
Spending Account (FSA) below Back to top
Payment for services on a "per person"
basis, rather than "Fee for Service". For instance, a Dental HMO
may contract with a Dentist to pay the Dentist monthly for every patient on their
roster, rather than reimburse the Dentist for every claim.
Back to top
Insurance Companies or Health Plans are commonly
called "Carriers". The terms Insurer, Insurance Company, Health
Plan and Carrier are virtually indistinguishable in this case.
Back to top
Groups sometimes choose to insure a portion of
their employees. The most common classes of employees to carve-out are
Union/Non-Union, Management/Non-Management, or Salary/Hourly. Other
classes of employees can sometimes be carved-out also. Back to top
Cash Value Life Insurance
See the definition for Life
Insurance below Back to top
A Health Plan with a High Deductible, and usually
no copays. The plan is not designed to cover the "every day medical
expenses", but it is designed to protect the insured from a catastrophic
loss, due to large claims. They commonly have Deductibles of $2,500, or
$5,000, or more. The premium is lower for this type of plan. Back to top
Legal, detailed documentation of your
coverage. A Policy is a contract between an Individual (or Entity) and the
Insurance Company. A Certificate of Coverage is for those who are covered
under a Group Plan, or a common Policy. Back to top
This is a certificate you may receive after
leaving a health plan, stating
that your prior insurance plan qualified as "Creditable Coverage". This may be very
important to ensure that you are given your rights to
"Portability". See the definition for HIPAA
Portability - 2 types below.
Back to top
Employees can be "classed" for several
purposes. Most Insurance Companies allow 2 classes, and many allow 3
classes. The most common classes are:
Class I - Owners, Officers, Managers
Class II - All other Employees
Often, there is a difference in the Waiting
Period for Newly Hired Employees, and in the Employer Contribution, depending
upon these classes. For instance, an Employer may choose that Class I
Employees have a 30 day waiting period, and receive 99% Employer Contribution
toward their premium, whereas Class II Employees have a 90 day waiting period,
and receive 75% Employer Contribution.
Sometimes, Employees are "classed" in
order to do a "Carve-Out". See the definition for Carve-Out
below
Back to top
A
Federal Law (Consolidated Omnibus Reconciliation Act), which requires
Employers with 20 or more full-time employees to offer continuation of Group
benefits to covered Employees & their dependents, who lost coverage due to a
"qualifying event". The most common "qualifying
event" is the loss of a job that results in the loss of Insurance
coverage. The "continuation coverage" is exactly the same
coverage as regular employees have, and there are no new pre-existing conditions
clauses or exclusions. The premium is the same (plus a 2% administrative
charge), but the COBRA participant pays the whole premium, including the
part the Employer previously contributed. There are many deadlines
& time frames that apply.
We offer plans for Administration of COBRA (ranging from Self-Administration software to full Administration), by companies
that are experts in Human Resources Compliance. Click here for more
information.
Back to top
A
percentage. For instance, many
plans have a Deductible, then pay 80%, and you pay 20%.
The 80% and 20% is called Co-Insurance.
Note that there is an “Out-of-Pocket” maximum to your
Co-Insurance. Click here for a description of
“Out-of-Pocket”. Back to top
Consumer-Driven Health Plans (sometimes called
Self-Driven Health Plans) are the newest market trend to come on the
scene. Actually, they are an old idea that has been re-born during this
time of escalating healthcare costs. The idea is to use a
"catastrophic" type of insurance coverage (usually a High Deductible
Health Plan). Your premium should be lower. Then, you set aside a
cash fund, with the premium savings. If you have a medical event, you have
cash to pay the bill. If your annual medical bills are large, and you meet the deductible on your health plan, the Insurance policy's
benefits begin.
"Consumer-Driven Health Plan" is a
broad term. Specific types of plans that are used as CDHP's include HSA's
(Health Savings Accounts), HRA's (Health Reimbursement Accounts or FSA's
(Flexible Spending Accounts).
Click here for more detailed information about
all of these types of CDHP's.
Back to top
Contribution usually refers to Minimum Employer
Contribution. This is the amount the Employer MUST pay for the Employee's
premium for Group Plans. Insurance Companies stipulate the minimum the Employer must pay,
and it is quite often "50% of the Employee's premium, but nothing for dependents".
Many Employers pay more than the minimum. Some Employers pay nearly all of
the premium for Employees, as well as for Dependents. Industry norms
usually guide the Employer, and we can help Business Clients benchmark their
Benefits & Contribution amounts to compare to their competitors, location,
and the employment marketplace.
To attract and retain qualified personnel, some
Employers "class" the Contribution. For instance, they may pay 99% for
Owners/Officers & Managers, and 75% for all other Employees. This is
allowable, so long as it is non-discriminatory between classes.
We do not recommend Employer contributions of
more than 99% of the premium, due to non-discrimination laws. If an
Employer contributes 100% of the premium, Employees are NOT allowed to
voluntarily waive coverage, even if they have other coverage. By reducing
the Employer Contribution to 99%, an Employee could waive coverage, without
violating non-discrimination rules.
Contribution may also mean an amount deposited
into an account, such as a Health Savings Account.
Back to top
A nominal fee that you pay for healthcare
services. For instance, your plan may require a $20 copay for a visit to
the Doctor's Office. This means that you pay $20 to the Doctor's Office
when you receive the healthcare service. Most often, the Deductible DOES
NOT APPLY to services that require a copay. Back to top
Creditable Coverage is the type of coverage that
can be credited for HIPAA Portability purposes. This is explained further
in the section describing your HIPAA Portability rights. See the
definition for HIPAA Portability - 2
types
below. Back to top
An amount of your healthcare expenses that YOU
pay before some benefits begin. Usually the deductible is on a
calendar-year basis (which means it begins again every January 1st).
Usually families are protected by a limit on the number of Deductibles that
could apply to one family (called a "family maximum" for
Deductibles).
Quite often, the Deductible is required for
hospitalization and other "Major Medical" types of expenses.
However, almost always, the Deductible is NOT required for services that require a
Copay,
such as Copays for visits to the Doctor's Office, or for
Prescriptions. Back to top
Dental Plans pay for Dental expenses, from
Preventive Care to Major Restoration, and sometimes Orthodontia (Braces). Click
here for more information about Dental Plans for Employer Groups and for
Individual/Families.
Dental expenses are usually not covered under a
typical Health Insurance plan, except for accidental injury to sound natural
teeth, and sometimes Oral Surgery or treatment for TMJ (Temporomandibular Joint
Dysfunction).
Back to top
A billing code. When your Doctor (or the
Hospital) bills the Insurance Company, they include a "Diagnostic
Code" (sometimes called a Billing Code or CPT Code). This code is
like an itemized invoice for Insurance claims. It specifies exactly what
the procedure or service entailed, and it is accompanied by a billed amount.
The Insurance Company makes their payment based on what is allowed (or billed)
for each particular code. The most common claim problem that we encounter
is when a Doctor or other healthcare Provider used the wrong code.
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Diagnostic X-Ray & Lab (DXL)
See the definition for X-Ray
& Lab below Back to top
Disability plans replace a percentage of your paycheck in case
you can't work due to an injury or sickness. Click
here for more information about:
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Most plans allow you to visit a Doctor's Office,
and only pay a nominal fee (such as $15 or $20), called a Copay. After you
have paid your Copay, the Insurance Company pays the rest of the Doctor's
bill. Sometimes
the Copay is higher if you visit a Specialist, than if you visit a Primary Care
Physician. Most often, the Deductible DOES NOT APPLY to services that
require a copay. Back to top
Groups often give their employees 2 or 3 plan
choices (called Dual or Triple Choice). Historically, these choices have
been between an HMO or PPO. Now, however, with the introduction of
Consumer-Driven Health Plans (CDHP's), such as Health Savings Accounts (HSA's),
many Businesses give their Employees a choice between a regular PPO, and an
HSA. In tough financial times, some Businesses will contribute toward a
stripped-down benefit plan, like a "Catastrophic" or "Basic"
plan, then allow their employees to "buy-up" to a higher benefit plan.
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Employee Assistance Programs offer benefits for
legal, financial, psychological, and domestic issues. EAP's can be
integrated into a health insurance program, or can be a separate stand-alone
product.
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After the application is approved, an Effective
Date is established, which is the date the Insured person(s) can begin using the
Insurance plan. Effective dates are usually the first of a month.
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A determination of who is allowed to enroll in,
or receive benefits from an Insurance plan.
The contract (Certificate of Coverage or Policy)
will spell out the requirements for Eligibility, which usually includes the
insured person, and valid dependents. Age limitations and residency
requirements sometimes apply.
For enrollment in Group Insurance,
"Eligibility" usually refers to the class of Employees who are allowed
to enroll in the Insurance plan. Most often, Eligibility is defined as "full-time,
regular Employees, who have exceeded the waiting period for newly hired
employees". The definition of "full-time" is set by the
Employer. Unless the Employer stipulates otherwise, it usually excludes
Part-Time, Seasonal & Temporary Employees. If the Employer
chooses, most plans will allow enrollment of Independent Contractors who receive
a 1099 instead of a W-2.
See the definitions below for "Full-time",
and "Waiting Period for Newly Hired Employees".
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A waiting period on Disability plans &
Long-Term Care plans. It is the amount of time you must be disabled (or
confined to long-term care) before the benefit checks will begin.
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A department of the Hospital,
meant to treat Emergency medical conditions on an Out-patient basis. Today, the over-use of
Emergency Rooms is such a problem that Health Plans often require a fee, in
addition to the Deductible & Co-Insurance. Some plans still only
charge a Copay, but the Copay for Emergency Rooms is larger than the Copay for
Urgent Care centers. Check your plan benefits carefully, and try to use
the Urgent Care centers, instead of Emergency Rooms for non-emergent
situations. Back to top
Employer Contribution
See the definition for Contribution
above. Back to top
Employee Benefits (or Group Plans)
See the definition for Group
plans below. Back to top
Most commonly this means health questions on the
application. You must answer these questions, so the Insurance Company can
decide if you are "Insurable", and if they will approve your
application. Evidence of Insurability (E of I) may also include information
about your occupation, hazardous avocations, and other factors that affect the
risk the Insurance Company would assume.
Applicants for Individual/Family
plans must provide a large amount of information on the application.
For
Group plans, there are fewer questions, and they can only be asked once - at the
time of the initial Group Application for the plan. From that point on,
Employees who enroll when they are first eligible, will be allowed to enroll
without answering health questions or supplying "Evidence of |
