Arizona Health Insurance and Medical Plans in AZ  

Health Insurance Specialists, Inc.
       
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Frequently Asked...

Call a Specialist in health insurance in Arizona - free quality customer service

Phone:   (480)  219-4270
       
8 am - 5 pm MST
Email:  click here for e-mail

FAQ's and Glossary  - the complete list follows:

Types of Coverage

  • COBRA

  • FMLA (Family Medical Leave Act)

  • HIPAA  (Health Insurance Portability & Accountability Act)

 

Glossary

 


Answers to "Frequently Asked..."

I want to lower my premium?
  • 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.

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My Employer’s plan is costly for my Spouse & Kids
  • 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

Is my Doctor in the Network?
  • 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

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I'm changing jobs; what options do I have?
  • 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


I have Pre-Existing Conditions to cover

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.  

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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

I need to talk to someone in person
  • 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.

What is an HMO or PPO?
  • 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:

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I need a brief overview of how Health Insurance plans work, including Copays, Deductibles & Co-Insurance

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.

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I live outside AZ, what plans will cover me?

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.  

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Will I pay an extra fee to use your services?

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. 

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Am I selecting a good quality plan?
  • 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.

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Why are Individual/Family plans so much cheaper than Group plan?

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.

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May I cover my Kids only? 
  • 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.

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Can I insure my Employees on a number of Individual/Family plans, but have my business pay for it?

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.

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Can my Health Insurance policy be cancelled, or the rates increased, because my claims are high?

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.

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How do I find my rate for an Individual/Family plan?

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


How do I apply for coverage?

Click here.  You can get applications for all the plans, available by mail, fax, printable pdf file, or downloadable.  Back to top


How do I get a quote for an Employer Group plan for my business?

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


How do I apply for Short-Term Health coverage to begin as soon as tomorrow?

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.  

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How do I follow the process of my application once I send it in?

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"

AD&D

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


Agent (or Broker)

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


AHCCCS

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


Alternative Funding
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:

  • FSA's (Flexible Spending Accounts)

  • HRA's (Health Reimbursement Arrangements)
  • HSA's (Health Savings Accounts)
  • CDHP's (Consumer Directed Health Plans)
  • Self-Funding or Partially Self-Funding
  • Section 125 Premium Only Plans (Tax-Free Premium Plans)
  • Voluntary Benefits (highly or fully paid by the Employees

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Application

A form one submits to the Insurance Company, in order to enroll in, or apply for Insurance coverage.   Back to top


Application Fee

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


ASO (Administrative Services Only)

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


Balance Billing

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


Benefit Summary

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


Capitation

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.   

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Carrier

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


Carve-out (aka Management Carve-Out)

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


Catastrophic or Basic plan

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


Certificate of Coverage (COC), or Policy

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


Certificate of Creditable Coverage (CCC)

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.  

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Classes of Employees

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


COBRA
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.

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Co-Insurance

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 (CDHP's)

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.  

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Contribution

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. 

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Copay (or copayment)

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

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


Deductible

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 (all types)

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).  

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Diagnostic Code

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 Insurance (Long-Term Disability & Short-Term Disability)

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:

  • Group Disability (for the Employees of a Business)

  • Individual Disability
  • Long-Term Disability
  • Short-Term Disability
  • Key Person Disability
  • Business Overhead Expense

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Doctor Visit Copays

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


Dual / Triple Choice

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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EAP's (Employee Assistance Program)

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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Effective Date

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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Eligibility

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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Elimination Period

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.                          Back to top


Emergency Room (ER)

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


Evidence of Insurability (E of I)

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 Insurability".     Back to top


Exclusion

Items that are NOT covered under your policy.  Sometimes this is called Limitations.  

Another usage of the term "Exclusion" is about an Exclusion Rider (also called a Waiver), which is an agreement, attached to the policy, and accepted by the insured.  It states that the Insurance Company will accept you as an Insured, but they will EXCLUDE coverage for a particular medical condition.     Back to top


Explanation of Benefits (EOB)

Documentation of your claim.  When an Insurance Company processes your claim, they return an EOB to you, and one to your Provider of the healthcare services.  This EOB details the claim, including who is the claimant, who is the Provider, what is the date of service, the amount of the billed charges, the amount that the Insurance Company allows, the Discount that the Provider must give you, the amount the Insurance Company pays, and the amount you must pay.  The amount you must pay is clearly categorized (such as a copay, a deductible, etc.)

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Fee for Service (FFS)

A method of claim payment that reimburses the Provider of healthcare services for the actual services that were rendered.  This is in contrast to "Capitation" methods of payment.     Back to top


Fee Schedule (or Allowable Amount)

A schedule of the amounts an Insurance Company will consider "allowable" for particular healthcare services.  

In the case of HMO's and PPO's, this is the amount their "In-Network" Providers have agreed to accept.  That means, you get a discounted rate for healthcare expenses, because your Insurance Company has contracted with the Providers for this lower rate.  The In-Network Providers MUST discount their rates for you, and they are under contract to not "Balance Bill" you.  

When you use an "Non-Network" Provider, however, you may be "Balance Billed", because the Insurance Company will calculate the benefits according to their "Fee Schedule".  Non-Network Providers are not under contract to discount their charges.

Fee schedules vary by Insurance Company & Health Plan.  The most liberal schedules are referred to as "Usual, Customary & Reasonable (UCR)".  Some Insurance Companies use Medicare Allowable Rates.  

There are Insurance plans that use very limited Fee Schedules.  We carefully scrutinize the Insurance Companies, and the plans that we recommend to you, and we will not recommend plans that have abnormally limited Fee Schedules.  .     Back to top


FMLA (Family Medical Leave Act)

A Federal law, requiring Employers with 50 or more Employees within a 75-mile radius to provide up to 12 weeks of job protected leave in any 12 month period to covered Employees:

  • To care for their newborn after birth, placement for adoption or foster care
  • To care for an Employee's spouse, child or parent who has a serious health condition
  • For a serious health condition that makes an Employee unable to perform their job

We have plans that offer Administration for FMLA (ranging from Self-Administration packages to full Administration), by Companies that are experts in Human Resources Compliance.

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FSA's (Flexible Spending Accounts) - formerly known as Cafeteria Plans

A tax-favored program, for Businesses (Employee Benefit plans).  Click here for more detailed information about FSA's.  

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Full-Time Eligibility (Part-Time, Seasonal & Temporary Employees)

The definition of Full-Time Employee is most often set by the Employer at the time of the original Group application for coverage.  Definitions of full-time can be between 20 hours per week to 40 hours per week, with the most popular choice being 30 hours per week.  

On Group plans, eligibility usually includes Full-Time, regular employees.  This can be W-2 employees, and often even 1099 Independent Contractors.  Unless the Employer stipulates otherwise, it usually does not include Part-Time Employees, Seasonal or Temporary Employees  

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Group Plan (or Employee Benefits)

A master policy, purchased by an Employer, which covers the Employees of their business, and the dependents of those Employees.  Group plans are also known as Employee Benefits.  Employee Benefits may include Dental, Disability, Vision, or other types of benefits, as well as Health Insurance.  

Employee Benefits are highly valued in order to attract and retain quality personnel.  Studies show that Employees value their Health Insurance benefits second only to Base Pay as a reason to select or keep a job.  The most common type of Group Plan is Health Insurance.  Attractive features of Group Health Insurance include:

  • Composite rates - blended rates that are the same for every Employee, no matter what the age, gender, or number of children in their family.
  • Easy enrollment - Newly hired Employees will not be asked health questions in order to qualify to enroll in an existing group plan.  Also, Employees who previously waived can enroll again at Open Enrollment, and many times they can enroll mid-year.
  • Better benefits - A richer, broader array of benefits, with higher levels are allowed on Group plans.
  • Custom Design - Employers can semi-custom, or fully custom design their plans.
  • Underwriting -  Attractive Underwriting features include:
    • Guaranteed Issue - By law, a business with 2-50 Employees may not be denied Health Insurance coverage, due to adverse health conditions.  However, the premium may be rated up if there are known health conditions at the time of the original application.
    • One-time Underwriting - An Insurance Company can only ask health questions at the time of the ORIGINAL application for the Group - not at renewal, and not when new Employees enroll. 
    • Group blending for Underwriting purposes - The Underwriter looks at the group as a whole, not at one particular individual's health history.  That means that a group, with one sick Employee will probably not even see a rate-up for that health condition, if there are several healthy Employees to offset or "dilute" the cost of the health condition.  
    • Simplified Underwriting - The amount of health questions asked on the application depends on the size of your group.  
      • Groups with 2-9 Employees are asked a number of health questions on the application, but it is still favorable to the Underwriting required for Individual/Family plans.
      • Groups with 10+ Employees have very few health questions on the Employee application, and the Underwriting is much easier.
      • Groups with 20+ Employees have "Employer Gatekeeper" applications (a few health questions are asked of the EMPLOYER only, to the best of his/her knowledge & belief), but there are NO health questions asked on the Employee applications.  

Click here to get more information and a premium quote for Group Insurance for your Business.

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Guaranteed Issue

Generally speaking, this is an insurance plan that will be issued, without requiring Evidence of Insurability.  In health insurance, it most commonly means the Insurance Company will not ask health questions to determine if you are eligible for the policy.

Specifically, there is a form of Portability rights, under the HIPAA Portability laws, commonly referred to as HIPAA (Guaranteed Issue) Portability.  See the definition for HIPAA Portability - 2 types below.                       Back to top


Guide for the Uninsured, and those having difficulty obtaining coverage

Click here for an extensive Guide.                                     Back to top


Health Insurance

A contract between an Insurance Company and an Insured, which provides for the payment of certain healthcare expenses.  The types of plans, and choices of benefits is wide and varied.  Click here for a brief summary of how most health plans work

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High Deductible Health Plan (HDHP)

A Health Plan with a large deductible.  Formerly known as "Catastrophic", or "Basic" plans, the definition has recently grown to include HSA's (Health Savings Accounts), and other CDHP's (Consumer Directed Health Plans).

A Qualified High Deductible Health Plan (QHDHP) is required for an HSA (Health Savings Account).  This plan has specific benefits, deductibles, and out-of-pocket maximums that are required by law to qualify for use with an HSA.  For more information on HSA's, click here.     Back to top


HIPAA (Health Insurance Portability & Accountability Act)

A federal law, which is the most sweeping reform of the health care system in the history of the United States.  The law is cut into 3 parts, which are:

  • Portability - Health Insurance reform, requiring "Portability" when one moves to and from a Group Health plan.  This is the portion that will probably affect the consumer the most.  Portability rights are extremely important, especially if you have a health condition, because it protects your rights to coverage, and to a credit or possible waiver of the pre-existing conditions clause.  To learn more about "Portability" rights, see the next two definitions below, or click here.
  • Privacy laws - which require the protection of private information, called "Private Health Information" (PHI).  We have programs for Business clients that provides for Administration of HIPAA privacy laws (ranging from a Self-Administration package to full Administration), by Companies that are experts in the field of Human Resources Compliance.  Click here for more information.
  • Billing & Claim reform - which require Providers to bill electronically, using certain code sets & procedures, and which require Insurance Companies to pay their claims electronically, using certain procedures & safeguards.

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HIPAA Portability - 2 types

There are two types of Portability rights under the Federal HIPAA (Health Insurance Portability & Accountability Act) Laws.  

  • One is for those enrolling in Group Plans (known as HIPAA "Certificate of Creditable Coverage" Portability)

  • The other is for those enrolling in an Individual / Family Plan (known as HIPAA "Guaranteed Issue" Portability)

These laws allow those who have had prior health insurance coverage to join a Group plan, or an Individual/Family plan, with rights to coverage.  There are several rules & time frames that must be met.  

HIPAA "Certificate of Creditable Coverage" Portability (for those enrolling in Group Plans) reduces or eliminates the Group Plan's pre-existing condition waiting period, by giving you "credit" (month-for-month), for the prior coverage that you have had.  Some of the main issues are:

  • This type of Portability is for those enrolling in GROUP plans only
  • You will get credit (month-for-month) for prior coverage that you have had.  This credit will be used to reduce or eliminate your pre-existing conditions waiting period on the new Group Plan.
  • You must not have had a lapse in coverage of 63 days or more (the waiting period for new-hires to become eligible for their Employer's plan is not included in the 63 days).
  • You can use any combinations of "Creditable Coverage" to prove that you have had prior coverage.  This includes Individual Plans and Group Plans.  More information about "Creditable Coverage" follows below.  

HIPAA "Guaranteed Issue" Portability (for those enrolling in INDIVIDUAL/FAMILY plans).  This allows you to purchase an Individual/Family plan, without medical underwriting (meaning there will be no health questions asked before you are approved).  The Individual/Family plans are identical to the ones marketed to the general public, except for three points - there is no waiting period for pre-existing conditions, you may not be turned down due to medical conditions, and the premium is far more expensive.  Some of the main issues are:

  • This type of Portability is for those enrolling in INDIVIDUAL/FAMILY Plans only.
  • You must have been insured for the prior 18 months.  
  • You must not have had a lapse in coverage of 63 days or more (the waiting period for new-hires to become eligible for their Employer's plan is not included in the 63 days).
  • your most recent coverage must be GROUP coverage (COBRA is also considered Group).  Caution - Enrollment in a Short-Term plan, or any other Individual plan will disqualify you.
  • You must have exhausted all COBRA rights that were available to you
  • You must not be eligible for other Group health insurance, Medicaid, Medicare or AHCCCS
  • You may not be covered under any other health insurance

For more information about all the eligibility rules, and about the benefits & premiums, contact the Insurance Company of your choice & ask about their HIPAA (Guaranteed Issue) Portability plans.

Creditable Coverage - Both types of HIPAA Portability require you to have prior coverage.  This must be "Creditable Coverage".  When you leave an Insurance plan, you will receive a "Certificate of Creditable Coverage" from your prior Insurer.  Use this document as proof of your prior coverage.  If you do not have this document, order another one, or use other documentation to prove that you had coverage (such as proof of claims payments, proof of premium payments, copies of old ID cards, etc.)  Most Insurance Companies will work with you to accept valid proof of prior coverage.  Many of them will even call your prior Insurance Company to verify that you were covered.  

Caution - be sure that you know which types of Insurance plans qualify as "Creditable".  Most Group & Individual plans qualify, if they are traditional types of health insurance, such as HMO's, PPO's, HSA's, etc.  Also, Governmental plans qualify, such as Medicare, Medicaid, AHCCCS, Indian Health Services, etc.  You can have any combination of these plans, with several Insurers and/or several different jobs.  However, limited-benefit types of plans DO NOT qualify as "Creditable".  Examples of Limited Benefit Plans include Medical Discount Plans, Hospital Indemnity Plans, Specific Disease Plans (such as Cancer Plans), etc.  

Remember, if you are applying for HIPAA "Guaranteed Issue" Portability (for Individual/Family plans), your most recent coverage must have been GROUP coverage.

This brief description of HIPAA Portability rights is not intended to be a full description, nor is it intended to be legal advice.  Most Insurance Companies will provide you with more information about your Portability rights, if you call them directly and ask for it.  

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HIPAA Privacy

Laws requiring Protected Health Information (PHI) and other personal information to be protected.  Click here to see our own Privacy Notice.                                         Back to top


HMO (Health Maintenance Organization)

Health Maintenance Organization - a system of managed healthcare created in the 1980's to control costs.  The idea was to require members to use a "Primary Care Physician", and to use certain Hospitals and other Providers in a Network, who had contracted with the Insurance Company to accept discounted rates, and to control over-utilization through managed healthcare.  During the 1980's and 1990's, it provided lower-cost insurance plans, with higher benefits.  Today, it is almost obsolete.  However, it is still a valid option for those who want an Individual/Family plan that includes maternity coverage.  Click here for a brief comparison of the difference between an HMO & PPO.       

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Hospital Copay

A fixed dollar amount you pay "per day" or "per admission" to the Hospital.  There is usually a limit to how much you could pay in a calendar year, in case you were hospitalized for several days.  Very few plans require an Inpatient Hospital Copay, except HMO's.  Usually, if an Inpatient Hospital Copay is required, then a Deductible is not required.     Back to top


HRA's (Health Reimbursement Arrangements)

A tax-favored program, for Businesses (Employee Benefit plans).  Click here for more detailed information about HRA's.  

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HSA (Health Savings Account)

Health Savings Account.  This is the new idea that President Bush is touting.  Actually, it’s a re-creation of an old idea.  The idea is to use a “catastrophic” type of insurance coverage, called a High Deductible Health Plan (HDHP).  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 satisfy the deductible on your health plan, the insurance policy’s coverage kicks in.  To add frosting to the cake, the money you set aside in your cash fund is TAX DEDUCTIBLE.  Click here for more detailed information about HSA’s for both Individual/Families, and for Businesses (Employee Benefits)..     

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Human Resources Compliance & Administration Programs

A program of Guidance & Administration provided by Companies that are experts in the field of Human Resource Issues, including HR Laws & Compliance.  These plans, range from Self-Administration packages to full Administration and on-site training.  Click here for more information about HR Compliance programs for:

  • COBRA Continuation of Coverage (Consolidated Omnibus Reconciliation Act)

  • FMLA (Family Medical Leave Act)

  • HIPAA Privacy Laws (Health Insurance Portability & Accountability Act)

  • Employment Law, including:

    • Wage & Hour

    • FLSA (Fair Labor Standards Act)

    • ADA (Americans with Disabilities Act)

  • Employment Policy and Procedures, including:

    • Employee Handbooks

    • Safety Programs

    • Sexual Harassment

    • Hiring / Firing procedures

    • Other Human Resource procedures

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Imaging (Major Imaging)

Costly diagnostic testing (usually performed at a Hospital), such as MRI, CAT Scan, PET Scan, Nuclear Medicine, etc.  The benefits for these tests are usually different than for simple imaging, such as X-Ray, Mammogram, etc.  

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Independent Agent

An Agent (or Broker) who does not work directly for an Insurance Company, but is an Authorized Representative of many Insurance Companies.  We, at Health Insurance Specialists, Inc.,  are Independent Agents.   Back to top


Independent Contractor (1099 Employee)

See the definition for 1099 Employee below.       Back to top


Individual/Family Health Plans

An Insurance plan that you buy on your own, rather than through an Employer's Group plan.  Click here for a benefit comparison of the Individual/Family Health plans, a quick way to find the premium rate for you or your family, and helpful guides to help you compare the plans, and apply for coverage.   

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In-Network

Inclusion of a Provider on a list of "Preferred Providers", as opposed to other providers who are "Out-of-Network, or Non-Network" Providers.   Back to top


KidsCare

A Federal and State program providing Health Care for children under age 19, living in families with incomes below 200% of the Federal poverty level ($3,225 monthly income for a family of 4).  It is free for most low-income families, but some may have to pay a modest monthly premium, not to exceed $25 for one child or $35 no matter how many children you have.  Click here for the KidsCare website.  

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Lab & X-Ray (DXL)

See the definition for X-Ray & Lab below.      Back to top


Life Insurance & AD&D ( Term Life or "Cash Value Life Insurance", such as Whole Life, Universal Life, Variable Life, etc.)

Life Insurance is an Insurance policy intended to protect against financial loss due to the death of the Insured. 

Most often, Life Insurance is used to protect families in case a parent or spouse is no longer alive.  The second most common usage for Life Insurance is for loans, and business interests.  

There are various types of Life Insurance, including Term Life, Cash Value Life, Whole Life, Universal Life and Variable Life, briefly explained in our Life Insurance section.   

Click here for more information and premium quotes for life insurance

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Long-Term Care (Nursing Home Plans)

Designed to pay the high coast of Nursing Home Care or Home Health Care if you are unable to care for yourself, due to accident or illness.  

Click here for more information and Premium Quotes for Long-Term Care Plans.

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Long-Term Disability

See the definition for Disability Insurance above.      Back to top


Major Medical

Today, "Major Medical" is often used to identify those types of expenses that are covered under a Health Insurance plan, but are subject to the Deductible and Co-Insurance, rather than subject to a Copay.

Historically, however, the term "Major Medical" meant a Traditional, Indemnity style of Health Insurance policy, without copays, and usually with a modest to large deductible.  

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Management Carve-Out

See the definition for Carve-Out above.      Back to top


Maternity Coverage

Coverage for Pre-Natal, Post-Natal, Labor & Delivery charges for pregnancy, including the many Office Visits to the Obstetrician before birth, Hospital Charges for Delivery, and follow-up visits.

Group plans almost always cover Maternity in full, without a waiting period.  By law, Maternity is not even considered a pre-existing condition, and not subject to a pre-existing conditions waiting period on a Group plan.

Individual/Family plans often only cover Maternity if an HMO is selected.  Furthermore, these Individual / Family HMO's usually have a waiting period, before normal maternity benefits are covered.  These waiting periods differ according to the Insurance Company, and the actual wording can be very important.  Please read our Benefits-at-a-glance, and the Insurance Company's brochures, as well as the policy for more information.  

Although there is an extra charge, and although there is a waiting period before Maternity benefits are allowed, HMO's are the only Individual/Family plans that offer true Maternity benefits.  Other plans (such as Individual/Family PPO's), usually only cover complications of pregnancy, not Maternity.  (Sometimes, a rider is available, offering Maternity benefits on a PPO, however, we rarely recommend the rider, because the extra premium, limited benefits, and the waiting periods are excessive.)

Addition of the Baby - Please note that a newborn baby can be added to the parent's policy (from moment of birth), provided certain deadlines are met.  The deadline is usually 30 days.

Teenage Daughter's Pregnancy - Maternity coverage often includes the pregnancy of a daughter who is covered under her parent's policy.  However, the newborn baby is rarely eligible for coverage under the policy, because it is the grandchild, not the child of the policyholder.

Caution:  If you are already pregnant, or if you are the Father of an unborn child, you have several obstacles to obtaining new health insurance.  

  • First, none of our  Individual / Family plans will cover a Pregnant Mother.  You should remain on any Group plan that you have.  Group plans offer easy enrollment, and Pregnancy is not even considered a Pre-Existing Condition for Group Plans.
  • Second, Individual / Family plans will not cover the Father of an unborn child (because the Insurance Company would be required to cover the baby from the moment of birth).  The Father should remain on a Group plan, or enroll in a Short-Term plan that will accept Expectant Fathers (but not the pregnant mother or the newborn child).
  • Third, If you have other children in the household, there are some Individual / Family plans that will cover those children (but not the expectant parents or the newborn baby).  Call us for more information.
  • Fourth, you may wish to read the Guide for the Uninsured and those having difficulty obtaining healthcare coverage, for more options, including COBRA, HIPAA Portability, and governmental programs.

Click here for a Benefit Comparison, and Premium Quote for Maternity coverage on an Individual Family HMO Plan.

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Medical Discount Programs

A program allowing patients to access a network of Providers, and to receive the same kind of discounts given to large Insurance Companies.  These discounts can be significant.  However, this is not health insurance, but is a Discount Program only.  For people who cannot get Health Insurance otherwise, such as those who have adverse medical conditions and are not eligible for any type of Insurance plan, Medical Discount Programs may be their only alternative.  

Click here for a Guide for the Uninsured and/or for those having difficulty obtaining healthcare coverage.  This guide describes Medical Discount programs in more detail, including cautions about their limited benefits.  

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Medicare (Parts A & B, Medicare+Choice, Medicare HMO, Medigap & Medicare Supplements)

Medicare is a Federal program that provides health care coverage to persons age 65 and older and to the totally disabled.

Click here for more information about Medicare Parts A & B, as well as Medi-Gap (Medicare Supplements), and Medicare+ Choice (Medicare HMO's).

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Medicare+Choice (Medicare HMO)

An alternative to original Medicare, allowing you to use the system of an HMO for healthcare coverage.  Click here for more information about Medicare+ Choice (Medicare HMO's).

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Medigap (Medicare Supplement)

A Supplement to Medicare, covering some gaps in Medicare benefits.  Click here for more information about Medi-gap (Medicare Supplements)         Back to top


Multi-State Locations

Businesses with Employees in who reside in other States, or Foreign Nations.  We have access to Plans and Networks to provide coverage for Employees in all 50 States, and even in Foreign Nations.

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Network

A list of Providers who are contracted with the Insurance Company to discount their fees, and to keep the quality standards, rules & regulations required by the Insurance Company.

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New Hire Waiting Period

See the definition for Waiting Period for Newly Hired Employees below.                     Back to top


Non-Network (or Out-of-Network)

Providers who are NOT in the Network (are NOT contracted with the Insurance Company to discount their fees, and to adhere to other rules & quality standards)

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Nursing Home Plans (Long-Term Care)

See the definition for Long-Term Care above.      Back to top


OOP (Out-of-Pocket Maximum)

See the definition for Out-of-Pocket Maximum below.   Back to top


Open Access HMO (OA HMO)

An HMO that does NOT require you to select one Primary Care Physician (PCP), to refer you to Specialists.  You must still use the Network of Providers, but you are given more freedom to choose a variety of Providers from the Network.

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Open Enrollment

A window of opportunity to enroll or change options in an Employer's Group plan.  Usually, Open Enrollment is the 30 days before, and/or the 30 days after the renewal of the Employer's Group plan.  This is the time in which an Employee may enroll and/or switch from one plan option to another.  

Sometimes other mid-year enrollments are allowed, especially if there has been a "qualifying event", such as the loss of other group coverage offered through a Spouse's group plan.

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Out-of-Network (or Non-Network)

See the definition for Non-Network above.             Back to top


Out-of-Pocket Maximum (OOP)

This is a ceiling to the amount YOU pay as your "co-insurance percentage".  This protects you against catastrophic bills.  

For instance, many plans have a Deductible, then pay 80%, and you pay 20%.  (The 80% and 20% is called Co-Insurance.)  When your 20% reaches the "Out-of-Pocket Maximum", your percentage stops, and the Insurance Company kicks into 100% coverage.

The term "Out-of-Pocket" is confusing, as most people do not realize that it almost always means a limit to your Co-Insurance (not to your Deductible or Copays).  Remember to add your Deductible & Copays to get a better picture of what you could pay in a Calendar Year, for your medical expenses.

Note:  On our comparisons (Benefits-at-a-glance), we always show the Deductible as separate from the Out-of-Pocket maximums, because most Insurance Companies do this.  However, some Insurance Companies, on their brochures, include the Deductible in the Out-of-Pocket.  For simplicity & comparison purposes, we separate them.

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Outpatient Facility

A Facility (usually a surgi-center) that does not keep the patient more than 24 hours, and is not considered an in-patient Hospital.

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Outpatient Surgery

A surgery you have outside of an In-Patient Hospital setting (for instance, the surgery may be performed in a Doctor's Office, or in a Freestanding Surgical Facility).

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Partially Self-Funding (or Self-Funding)

See the definition for Self-Funding below.       Back to top


Participation

For Group plans, this is a regulation that requires a percentage of the eligible persons to enroll.  For instance, Group Insurance plans often require a minimum participation of 75% of ELIGIBLE Employees.  To make things easier, they will not count those Eligible Employees who are covered under another Group plan, before applying the 75% rule.  Participation rules vary by Insurance Company.

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Payroll Deduction Plans (Voluntary of Supplemental Plans)

See the definition for Voluntary Benefits below.               Back to top


Plans available for those who cannot afford, or cannot qualify for health insurance

The whole nation is concerned about the Uninsured, and how they will get access to Health Care and/or pay for it.  There are several programs intended to help, if not solve the problem.  Click here for a Guide for the Uninsured, and for those having difficulty obtaining healthcare coverage.

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Policy (or Certificate of Coverage)

See the definition for Certificate of Coverage above.       Back to top


POS Plans (Point of Service)

A marriage between an HMO and PPO.  It is called "Point of Service" because the level of benefits you receive depend upon the Provider that you choose.  For instance, if you use your plan like an HMO (by using a Primary Care Physician, who refers you to any Specialists), your benefits will be higher, with HMO-like copays.  If use use your plan like a PPO, by accessing Providers of your choice, and self-referring to Specialists, you will receive standard benefits like a PPO.  You can usually even go "Out-of-Network" at a greater cost to you.  

Group Employee Benefit programs often include a POS plan, but it is not as popular as a PPO.  Individual/Family plans rarely allow POS options.

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Portability (Creditable Coverage) for Employer-provided Group plans

See the definition for HIPAA Portability - 2 types above.  

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Portability (Guaranteed Issue) for Individual/Family plans

See the definition for HIPAA Portability - 2 types above.  

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PPO (Preferred Provider Organization)

Preferred Provider Organization - a system of Health Insurance managed care.  It allows you access to the Provider of your choice (no need to choose a Primary Care Physician), and it allows you to refer yourself to Specialists of your choice.  Benefits are greater if you use "Preferred" Providers (those who are on the Network).  However, you may go "Out-of-Network", at a greater cost to you.  Click here for a brief comparison of the difference between HMO's and PPO's.       Back to top


Pre-Existing Conditions

The term "Pre-Existing Conditions" has various meanings, in separate contexts, such as:

  • General use of the term "Pre-Existing Condition - it refers to a medical condition that existed before one applied for an Insurance Plan. 
  • Specific, narrowly defined clauses in the Insurance Contract - An Insurance Company will very narrowly, and very specifically define a Pre-Existing Condition in two situations:
    • Underwriting - when you apply for an Insurance plan, and you are asked to disclose medical conditions on the application.
    • Pre-Existing Conditions Waiting Period - the clause that states how long you must be Insured before the Pre-Existing Condition is covered.
      • Definition of "Pre-Existing Conditions"
        • In both situations, the definition of a Pre-Existing Condition will be clearly defined.  For instance, it is common to see wording such as, "a condition for which you had medical treatment (including medications), diagnosis or consultation with a medical professional".  
        • In both situations, the definition of a Pre-Existing Condition will include a "look-back" period (for instance a condition from the last 12 months).
      • Waiting periods for Pre-Existing conditions vary by plan.  Some do not have waiting periods, and others give exceptions to the waiting period.  Always read the definitions carefully.  

If you have a medical condition, it is very important that you learn about Underwriting, Pre-Existing Conditions Waiting Periods, and other options, such as HIPAA Portability rights, COBRA rights, etc.  Please see the Guide for the Uninsured, and those having difficulty obtaining health insurance.

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Preferred Provider

A Provider who is on the Network.  On most plans, you have better benefits if you see a Preferred Provider, than if you use a "Non-Network" provider.

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Premium

Your cost to buy an Insurance plan.  Usually this is quoted on a monthly basis.

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Premium Only Plan (POP, Section 125, or Tax-Free Premium Plan)

See the definition for Section 125 Premium Only Plan below.      Back to top


Prepaid Plan

A plan that pays its Providers on a "Capitation" basis, rather than "Fee for Service".  For instance, a Prepaid Dental Plan is a plan that pays its Dentists monthly for every Insured that is on the Dentist's "roster", whether or not the Dentist actually did any dental work for that Insured.  The Dentist is then under contract to give certain discounts to that patient when it comes time to have dental work done.  A "prepaid" system of payment is in contrast to a "Fee for Service" system that reimburses the Provider for a claim.

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Prescription Copays

A dollar amount you pay for each prescription.  Often an Insurance Company divides prescriptions into "Tiers", and applies a different copay to each tier.  Usually, generics, antibiotics, and drugs that are low-cost and much-prescribed, will fall into Tier 1, with a minimal copay.  Drugs that fall into the higher tiers are usually higher in cost, but they often have alternative low-cost drugs that appear in a lower tier.

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Preventive Care (or Well-Care)

Health Care for screening purposes, such as Mammograms, Routine Physicals, etc.  Preventive Care is also called Well Care, or Routine Physicals.  Most Insurance Plans offer excellent benefits (sometimes 100% coverage) for Preventive Care, in order to encourage good health.  Each Insurance plan defines what is considered "Preventive Care", but it usually includes Routine Physicals, Mammograms, Immunizations for Children, Pap Smears, and other routine screening & tests.  Some Insurance plans put an annual dollar limit on Preventive Care (such as $300 per year).  This may appear to be a low dollar limit, however, it only applies to routine screenings.  If your Doctor orders more advanced tests (such as MRI's, CAT Scans, Stress EKG's, etc.) it is because he suspects a medical condition.  Therefore, these additional tests would fall under the regular benefits of the plan, not under the limited "Preventive Care" benefits. 

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Primary Care Physician

A Doctor that provides general care for a patient, such as a Family Practitioner, General Practitioner, Internist and Pediatrician.  Some plans, such as HMO's, REQUIRE you to select a Primary Care Physician, which would refer you to any Specialist that you need.  Other plans, such as PPO's, allow you freedom of choice of doctors, but they still recommend that you use one doctor for your primary care.

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Privacy Notice

See the definition for HIPAA Privacy above.  Click here to see our own Privacy Notice                          Back to top


Provider

A source of health care, such as a Doctor, Hospital, Pharmacy, Dentist, Lab, Outpatient Facility, etc.

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Quote

A bid, or an estimate of the premium that would most probably be required for a particular Insurance plan.  Although quotes attempt to be accurate, based on the information known at the time, the actual premium may change, once all the facts are disclosed on the application, and the Underwriter makes a decision.

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QHDHP (Qualified High Deductible Health Plan)

See the definition for High Deductible Health Plan above.   Back to top


Rate (Premium)

Your rate usually means your Premium (your cost to buy the Insurance plan).  This is usually quoted on a monthly basis.  

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Rate Guarantee

A written guarantee from an Insurance Company stating how long it will be, until the rates increase.  For Group plans, this is usually 12 months.  For Individual plans, there is rarely a written rate guarantee, however, we will not recommend plans that have a history of raising rates more often than annually.  For Life Insurance, quite often the rate guarantee is longer term, such as 15 years, 20 years, or even lifetime.

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Rate-up

An increased charge, due to an increased risk.  For instance, an Underwriter may decide to approve your application for coverage, but to charge 15% more than the standard rate (a 15% rate-up).

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Referrals

A requirement of HMO's, giving the authority to your Primary Care Physician to select any Specialists that you may need.  

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Rider

An attachment to the policy, adding or limiting benefits.  For instance, you may purchase a rider that allows benefits for additional Vision coverage.  

Most often, for Individual/Family Health plans, it refers to an Exclusion Rider.  Click here for more information about Exclusion Riders.  

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Section 125 Premium Only Plan (POP or Tax-Free Premium Plan)

A tax-savings program, allowed through Section 125 of the IRS code, that allows Employees to use Pre-Tax dollars for their Payroll-deducted premiums.  Click here for more detailed information.

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Self-Funding (or Partially Self-funding)

Self-Funding is a method of Alternative Funding, in which the business pays its own claims, but often uses a Third-Party Administrator for Administrative Services Only (ASO).  

Partially Self-Funding protects the business from large losses, through various types of excess loss insurance.  

Click here for more detailed information about Self-Funding and Partially Self-Funding

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Short-Term Disability

See the definition for Disability Insurance above.         Back to top


Short-Term Temporary Health Plan

When you are between jobs, or you have a gap in health insurance coverage, you may cover that gap with a "Short-Term Temporary Health Insurance" plan.  It can become effective as soon as the day AFTER the Insurance Company receives the complete application, and it can continue month-to-month, for as long as 12 months.  Click here for more information, and to learn how you can apply for this type of plan.                                    Back to top


Specialist

A Doctor of specialized care, as opposed to a Primary Care Physician.  For instance, a Specialist may include an Orthopedic Surgeon, a Cardiologist, Oncologist, and even a General Surgeon.

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Supplemental Plans (Voluntary or Payroll Deduction Plans)

See the definition for Voluntary Benefits below.         Back to top


Take-over

A smooth transition between Insurance Carriers, regarding waiting periods and/or Deductibles.  For Instance, when a business changes Insurance Companies for a Group plan, the new Insurance Company may allow "takeover" of the Deductibles met under the prior carrier.  On Group Health Insurance, takeover for Pre-Existing Conditions is now regulated by the HIPAA Portability laws.  For Group Dental Insurance, takeover usually means that any person on the current Dental plan will not have a waiting period for Major Services on the new Dental Plan.  For Group Disability and Life, takeover may apply to Pre-Existing Conditions, and to special underwriting.

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Tax-Free Premium Plan

See the definition for Section 125 Premium Only Plan above.  

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Temporary Health Plans (Short-Term Health Plans)

See the definition for Short-Term Health Plans above.   Back to top


Term Life Insurance

See the definition for Life Insurance above.   Back to top


Travel Health Plans

A health insurance plan designed for travelers to foreign nations.  Many health insurance plans do not cover non-emergency care outside the United States.  Even if your plan does, there are problems with foreign claims that can be avoided by purchasing a Travel Health Insurance plan.  These plans are very inexpensive & easy to apply for.  Click here for more detailed information about Travel Health Plans.

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Underwriter

A person who makes the final decision about approval of an application for an Insurance plan.  The Underwriter may request additional information to make a decision (such as a request for medical records from your Doctor).  He/she may make a decision to approve the application, decline it, or to offer a modified contract.  Sometimes the term "Underwriter" applies to the Underwriting Department, or to the Insurance Company.

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Underwriting

A process, involving the Insurance Company's review of an application, in order to make a final decision about whether the application will be approved, denied or given an offer of a modified contract.

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Uninsurable

A condition, person, or entity that cannot qualify for an Insurance Plan.  Most often, this applies to a person who has a medical condition, which precludes him/her from finding an Insurance Company that would be willing to insure him/her.  Click here for a Guide for those who are Uninsured and/or having difficulty obtaining health care coverage.  

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Universal Life Insurance

See the definition for Life Insurance above.      Back to top


Urgent Care Center

A healthcare facility whose purpose is to provide care for urgent needs, but not necessarily emergency needs.  Insurance Companies usually provide coverage for the use of an Urgent Care Center, with very modest copays (much lower than the copays for use of an Emergency Room at a Hospital).  Urgent Care Centers are usually free-standing facilities (not attached to a hospital), with extended hours, including weekends.  They usually treat conditions ranging from fevers to broken legs.  

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Usual, Customary & Reasonable (UCR)

Amounts charged by Health Care Providers that are consistent with charges from similar Providers for identical services, in a given locale.  

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Vision Plans (all types)

A benefit that pays for Vision expenses, such as Routine Refractive Eye Exams, and/or for Eyewear such as Contact Lenses, Glasses (Frames & Lenses).  This can be a limited benefit that is part of your Health Insurance plan, an additional benefit that pays for more Vision care, or even a separate Vision policy.  There are 2 kinds of Vision plans:

  • Traditional Plans that reimburse you for actual claims for Routine Refractive Eye Exams, and/or Eyewear such as Contact Lenses and Glasses (Frames & Lenses).  These plans can utilize a Network of Preferred Providers, or may pay benefits if you use any Optometrist or Ophthalmologist.
  • Discount plans that require you to use a Provider that is on their Network, then allow you to have a discount on the cost of the Routine Refractive Eye Exam and/or Eyewear.

Please note that some medical care of the Eye is not considered "Vision" coverage, but is a part of the regular benefits of most Health Insurance plans (such as medical care for Cataracts, Glaucoma, accidental damage to the eye, infection of the eye, etc.)

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Voluntary Benefits (Supplemental or Payroll-Deduction Plans)

Employer Group plans that a business sponsors for its Employees, but does not pay for.  These plans often supplement the Employer's current Employee Benefit plan.  They allow Employees to voluntarily enroll in specialized Insurance plans, but to pay the premium themselves (often through Payroll Deduction).  Common plan types include Supplemental Life Insurance, Dental, Disability, and Vision plans.  

Sometimes, Payroll-Deduction plans include a menu of "limited benefit" types of plans, which we do not recommend.  Examples of "limited benefit" choices are Hospital Indemnity plans (those that pay "per day" in the hospital), specified illness plans (such as cancer plans), etc.  We feel that the Employee's money is better spent on a more traditional menu of plans to supplement his core benefits.

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Waiting Period (for Dental)

Some Dental plans have waiting periods before Major Services are covered (usually a 12 month waiting period).  Sometimes there is a waiting period before Basic services and Orthodontia are covered.  Many times, groups of 10 or more Employees can purchase a plan without waiting periods.  Waiting periods can usually be waived, if the group had prior dental insurance.    Back to top


Waiting Period (for Maternity)

See the definition for Maternity Coverage above.             Back to top


Waiting Period (for Newly Hired Employees)

A period of time that a newly hired Employee must wait before becoming eligible for a Group Insurance plan.  The most common waiting period is between 30 and 90 days, but can be as low as 0 days, and as high as 365 days.  Some businesses use "classed" waiting periods, such as 30 days for Owners/Officers and Managers, and 90 days for all other Eligible Employees.  

Insurance Companies may define the waiting period in days, or in months, but the terms are interchangeable, as MOST Insurance Companies consider every calendar month to be 30 days.

The effective date of coverage is most often the "First of the Month Following" (FOMF) the waiting period.  For instance, if an Employee was hired January 5th, and had a 30 day (1 month) waiting period, the effective date would be March 1st, because it is the First of the Month Following (FOMF) the waiting period.

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Waiting Period (for Pre-Existing Conditions)

See the definition for Pre-Existing Conditions above.            Back to top


Waiver

For Group plans, this means a voluntary refusal of coverage, as when an Employee "waives" his right to enroll in the Insurance Plan.

For Individual/Family plans, this refers to an Exclusion Rider attached to the policy, limiting benefits for a specific condition.  Click here for more about Exclusion Riders.

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Well-Care (or Preventive Care)

See the definition for Preventive Care above.             Back to top


Whole Life Insurance

See the definition for Life Insurance above.     Back to top


X-Ray & Lab (DXL)

DXL means "Diagnostic X-Ray & Lab".  These are healthcare services for Diagnostic Testing, such as X-Ray, Blood Tests, Urine Analysis, etc.  Sometimes DXL (Diagnostic X-Ray & Lab) includes Mammograms & Ultrasounds.  The benefits for X-Ray & Lab is usually better than for Major Imaging (such as MRI's and CAT Scans).  Sometimes, the benefits for X-Ray & Lab is even richer if the tests are being performed as a routine screening, called Preventive Care or Well-Care.  Note that your coverage could be different, depending on the place where the X-Ray & Lab was rendered (such as at a Doctor's Office, Freestanding Lab, or Hospital).  Often, (but not always), X-Ray & Lab performed at & billed by the Doctor's Office or a Lab is covered with just a copay.     Back to top


1099 Employee (Independent Contractor)

An Independent Contractor, who receives a Form 1099 for tax purposes, instead of a W-2.  Many times commissioned sales people are 1099 Independent Contractors, and many businesses wish to include them in the Employee Benefit Plans.  We have many plans that will cover 1099 Independent Contractors on the same basis as W-2 Employees.     Back to top


 

 



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