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