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Health Insurance |
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General Information Plan Types Medicare Supplement (Medigap) Temporary Health Insurance (Short-term Policy) Student Health Insurance Maryland Health Insurance Plan Group Health Insurance
From newborns to the elderly, everyone needs health insurance. The cost of medical care, whether you are sick or having an annual check-up, can add up to a lot of money. Health insurance is designed to cover those expenses you can’t possibly afford to cover yourself out of your day-to-day budget. And, since no one knows when a serious ill accidental injury may occur, being covered by a health insurance plan at all times is a necessity.
Most people who work full-time receive health insurance benefits through their employer. Your employer may offer one medical plan for everyone, or a selection of plans from which you select the best for you and your family. The later type of is called a “cafeteria” plan. The amount your employer contributes towards the monthly premium will vary from 0 to 100%, but most employers subsidize the cost of insuring both their employees and their family members.
If you change from one employer to another, you usually have the right to continue the same medical plan you had while you were an active employee until your new employer’s insurance takes effect. This continuation of coverage is called COBRA and can last from 18 to 36 months depending on the reason you lost coverage. You will have to pay up to 102% of the cost of the insurance while you are on COBRA. If you work for a small employer (under 20 employees) COBRA may not apply, but you may still have some temporary continuation rights available in the state in which you reside. If none of these options are available to you, don’t risk being uninsured. There are temporary health plans that will cover you for short periods while you find yourself uncovered.
When you need to see a medical professional, it is OK to be an educated consumer. Ask about fees and billing procedures in advance and double check to be sure he/she still belongs to your provider network. Also, if you have any questions about what is and isn’t covered, the best time to ask is before service is rendered. This will help you avoid unpleasant surprises when the provider’s bill arrives in the mail. Keep in mind that all plans require pre-approval for some services and medications. Insurance companies have toll-free 800 numbers with claims experts at the ready to advise you about the specifics of your contract. Once you have been to the doctor, the insurance company will send you an Explanation of Benefits (EOB), which shows what was charged, how much was paid to the provider and how much is your responsibility to pay. If you don’t understand something on your EOB or something is incorrect, call the 800# provided to discuss your issues. Don’t be shy about taking advantage of the available help. Your premiums pay for this service.
Important Note: Whenever you contact your insurance company claims department or your providers billing service, keep a written record of the date and time of your call, the representative’s name that assisted you and what was discussed. If you need to make a follow-up call, you can refer to your notes from your previous conversation.
In general, insurance rules and guidelines are controlled by the states. This is the case with health insurance as well. It is true that there are some federal laws with which all plans in all states must comply, but a general rule of thumb is that health insurance offerings and rules vary widely from state to state and are governed by the state in which the contract was issued and/or where the insured resides.
The following will give you a brief overview of the types of coverage available:
There are four main types of medical insurance plans. There is no one right choice for everyone, so it is important to understand the differences and weigh the benefits and costs before you purchase a plan.
Indemnity Plan: This type of coverage allows you to go to any medical provider or hospital you chose. You, your doctor or your hospital will submit a bill for care after the service has been received to your insurance company. You will usually be responsible for a deductible (the amount of medical expenses that you have to pay for before your insurance begins reimbursing you or paying your doctor). After the deductible is met, the plan usually pays a percentage of your expenses (for example 70% or 80%) until you reach a maximum amount you are required to pay during a calendar year. The amount unpaid by the plan is your out-of-pocket cost, or your coinsurance. Plans base their reimbursements on either a “usual and customary” scale, that is the prevailing rate for a particular procedure in your area, or a fee scale. How insurance plans calculate their share of the bill can vary widely. It is important for you to know how your plan works so you are not left with a bigger bill than anticipated. This potential additional expense is called “balance billing”, and is the difference between what your plan allows and what the provider charges. Any balance billed amounts do not count toward your out-of-pocket maximum and can amount to hundreds or even thousands of dollars.
Health Savings Account (HSA): This is a high-deductible plan that allows the insured to set aside funds on a tax-deductible, tax-deferred basis to pay for out-of-pocket costs. For the most current rules and regulations regarding HSA plans, check out the Federal Government HSA website. Most HSA plans follow the Preferred Provider Plan (PPO) model discussed above.
Preferred Provider Plan (PPO): This is probably the most common type of plan. Our agency sells more PPO’s than any other type of plan, because of its flexibility. PPO plans may or may not have an annual deductible, but they always have two benefit reimbursement scales, a higher in-network level and a lower out-of-network level. A PPO plan allows you to maximize your coverage by going to any medical provider within a network of primary care doctors, specialists, hospitals, labs and radiology centers. The network has negotiated reduced fees with these medical providers, so the overall bill will be less (sometimes significantly less) than usual and customary charges. When you go to a network provider, your out-of-pocket cost will be reduced as well—usually a fixed co-payment (such as $15 or $20 per visit) or a higher coinsurance percentage (such as 90% or 100%). With a PPO plan, you have the freedom to go to an out-of-network provider, but the plan will reimburse less of the cost of care (such as 60% or 70%) and your annual maximum out-of-pocket maximum is usually higher. In addition, if you visit an out-of-network provider, you may be “balance billed” for any amount over the negotiated fee. Again, balance billed amounts do not count toward your out-of-pocket maximum and can amount to hundreds or even thousands of dollars.
Point of Service Plan (POS): Like the PPO, this type of plan has a higher in-network benefit scale and a lower out-of-network benefit scale. The key difference is the insured chooses a “primary care provider” from the network. A primary care doctor is usually an internist, GYN, pediatrician or family practitioner, and he/she directs and authorizes care within the network for lab, x-ray and specialist visits by making a “referral” for these services. Most services require a co-payment, though some will require co-insurance. If a referral isn’t obtained in advance of receiving care or if the insured seeks care outside the network, the plan reimbursement is significantly reduced, you may be subject to balance billing and your out-of-pocket costs will be higher. Some carriers now offer “open access” POS plans that do not require a referral to see certain specialists as long as you select a provider from within the POS network.
Health Maintenance Organization (HMO): With an HMO, the insured selects a primary care physician (usually a family practitioner or pediatrician) to direct all care. Through “referrals”, patients gain access to specialists, lab tests, radiology, etc. Most services are covered with a modest co-pay. With the exception of true emergency care, coverage generally isn’t available without a referral. HMO’s are available in two models, a group model where patients are seen in multi-specialty centers and the individual practice model where patients are seen in a physician’s office. Some carriers now offer “open access” HMO plans that do not require a referral to see certain specialists as long as you select a provider from within the HMO network.
Seniors who work beyond age 64 for employers who offer group medical insurance have some decisions to make. Contact us to discuss the particulars of your situation.
A Medicare Supplement (or Medigap policy) is designed to cover most of the “gaps” in care through Medicare. The federal government mandates the benefits in 12 different plan types, referred to as Plan A, B, C, etc. Any insurance company that sells Medicare Supplement policies must include the mandated benefits. In other words, all Plan A policies from one company offer the exact same benefits as Plan A from another company, etc. Not all companies are required to sell all plan designs in every state, so it is important to check the availability of the plan and carrier you want in the state in which you reside.
Where Medicare Supplement policies differ from one insurance company to another is in the premiums they charge. Some companies rate your policy annually based on your current age while others rate your policy based on your age when the policy was first issued.
When you reach Medicare age, you will need to apply for Medicare Part A and Medicare Part B to be eligible for a Medicare Supplement. There are separate premiums for the Medicare Part B (which is currently $93.50 in 2007) and the premium you pay your insurance company for your Medicare Supplement. As long as you pay your premiums on time your policy is guaranteed renewable, which means it cannot be cancelled. Spouses cannot be covered by the same Medicare Supplement; each must purchase their own coverage.
Medicare now offers prescription drug benefits. The easiest method for selecting the plan which is best for you and/or your spouse is to visit the Medicare website.
For your convenience, we have provided a link to the official US government Medicare website. This site provides a wealth of information on Medicare, Medicare Supplement policies and access to informational brochures on a variety of topics that can be downloaded or ordered at no cost to you.
Temporary Health Insurance (Short-term Plan)
Sometimes individuals find themselves without health coverage for short periods of time. Examples might be: you recently moved to a new state, you started a new job which has a waiting period before benefits begin, you were laid off, you are healthy and seeking a less expensive alternative to COBRA, your previous employer’s health plan continuation period or COBRA has expired or you recently graduated from college, etc. To protect you or a family member from unforeseen medical expenses during one of these “in between” times, temporary health coverage (or short term medical) may be the answer and is available at a reasonable price. These policies can usually be put into effect in as little as 24 hours and can be purchased for 30 to 365 days.
Temporary health policies are usually traditional indemnity type plans, that is, there is a deductible and then the plan pays a percentage of your claims over the deductible (such as 80%). Some carriers offer a network of providers to help keep costs down and reduce the risk of “balance billing” (which occurs when providers charge more than the maximum fee allowed by the insurance company). Using in-network doctors and facilities whenever possible is the best way to reduce your out-of-pocket expenses and keep claim paperwork to a minimum.
Just because the application process may seem abbreviated, don’t assume that the insurance companies that write temporary health insurance will accept all applicants. Please keep the following in mind:
--There are fewer qualifying medical questions for this type of policy because any condition for which you have been treated or taken medication in the past (a pre-existing medical condition) is not covered. --These policies do not cover preventive care or maternity. --A temporary health policy will not be issued if anyone in your family is pregnant or if you have been declined for health insurance in the past. --Be sure to read all the information provided carefully regarding what expenses are covered and the specific policy limitations of the plan you are considering. --As with all applications for insurance, it is very important that you answer all questions fully and accurately to avoid the possibility of a claim denial or revocation of your policy. --An application for coverage does not guarantee acceptance. Your request for coverage will be reviewed by an underwriter and final approval can only be granted by the insurance company.
You may request coverage begin as soon as 12:01 am the day after you apply online and pay with a credit card. Please note that insurers will not allow coverage to begin on the 29th, 30th or 31st of the month, so the earliest effective date possible for any application completed on the 28th through the 31st of the month is the 1st of the next month. Also, be sure to purchase a plan for the entire time you will be without other medical coverage. If your temporary health plan period expires, you will need to apply for a brand new policy, re-qualify and any medical treatment you received under your first policy period will be considered pre-existing (that is, not covered) under your second plan.
Below are links that will take you directly to insurance company sponsored/endorsed websites that provide information regarding rates, policy options and exclusions. Online applications are available through these sites, however we strongly encourage you to contact us to discuss your specific needs, your medical history and financial concerns before you make an online application. Plans vary by coverage, cost and underwriting parameters, so we would like to have an opportunity to help guide you to the plans that are best suited to your personal circumstances.
The insurance company links will advise you of the plans they have available in your state of residence, options, rates and available physician networks based on your age, plan, length of coverage and home zip code.
Feel free to contact us if you have any questions at all about temporary health insurance or if you do not see your state of residence listed below.
If you reside in Maryland or Virginia, you may select:
If you reside in North Carolina, you may select:
If you reside in Florida, you may select:
Some students can remain on their parents’ health insurance throughout their college years. However, this is not always an option for everyone. One such example would be if the parents have a regional health maintenance organization (HMO) in one part of the country and the student attends college somewhere where the HMO does not operate. Some colleges offer health insurance packages at reasonable rates, but be careful to read the policy carefully to be sure the student will have coverage away from college during semester breaks and throughout the summer months. When parents’ and college plans do not work well, private student health insurance plans are available.
Below is a link that will take you directly to an insurance company sponsored/endorsed website that provides information about their student health policy, options and rates. An online application is available through this site, however we strongly encourage you to contact us to discuss your specific needs, your medical history and financial concerns before you make an online application. Plans and coverage vary by state. If we have an opportunity to speak with you personally, we can review your health history, discuss costs and underwriting parameters and ultimately guide you to the plan that best suits to your personal circumstances.
Be sure to read all the information provided carefully regarding what expenses are covered and the specific policy limitations and out-of-pocket expenses of the plan you are considering. It is very important that you answer all questions fully and accurately to avoid the possibility of a claim denial or revocation of your policy. An application for coverage does not guarantee acceptance. Your request for coverage will be reviewed by an underwriter and final approval can only be granted by the insurance company.
For your convenience, we have also provided a link to the Private Healthcare Systems (PHCS) provider directory of physicians and facilities. This student health plan makes the PHCS network available to reduce claim costs and limit your responsibility for filing claims. Feel free to contact us if you have any questions about student health insurance.
Private Healthcare Systems Provider Directory
If you reside in Maryland, Virginia, or North Carolina please click below. If you reside in other states, please contact us for details.
Maryland Health Insurance Plan
This program is designed specifically for Maryland residents who do not currently have group or individual health insurance and have been declined for health coverage from an insurance company within the past 6 months. Written proof of the declination is required. This coverage is available without regard to your prior health history and is designed to provide needed coverage to individuals who otherwise would not be able to obtain coverage through the normal application process due to pre-existing health problems.
Employers with 2 or more employees are generally eligible to purchase group health insurance for themselves and their employees. Group insurance is available in six plan types, i.e. Indemnity, Preferred Provider Option (PPO), Health Savings Account (HSA) or Health Retirement Account (HRA), Point of Service (POS) and Health Maintenance Organization (HMO). These are described in the “Plan Types” section above. There are now hybrid plans and multi-option plans that combine some of the features of several plan types into one contract. These programs have been developed because one option alone does not always meet the best needs of an employer group. The benefit plans offered, the availability of guaranteed insurability and application processes vary widely by state and group size.
Small groups are usually considered to be employers with 2-50 employees. Plans offered for groups of this size are usually standardized by the insurance companies and contain certain benefits that are “mandated” in most states. Rates are usually banded by age and guaranteed for a one year period based on the demographics of your employees and the plan or plans you select.
Larger employers with 50 or more covered employees have more opportunity to customize their plan designs and can even self-fund some of the risk to keep their costs down. In addition to the benefits selected and inflation in medical costs, factors affecting the rates for group insurance may be based on: the average age of the group, male-to-female ratio, individual employee’s home zip codes, known health conditions, prior claims experience, etc. Generally, the rates for group plans are more attractive than individual health insurance because the insurance company uses the law of large numbers to pool poor claim losses over many groups.
If you are an owner or benefits manager for a group of 50 or more employees, please contact us to find out how our personalized service and large group expertise can work for you.
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