About Insurances: 11/23/08

Thursday, November 27, 2008

Interpreting Health Insurance Hieroglyphics Important Things to Know

Trying to figure out everything that is on your insurance policy can feel like trying to read a new language. Having an illness or non-work related injury is devastating enough, trying to figure out what is covered and what is not can be a whole other picnic. Especially when prices on health care have raised so much. Even though managed care can really save people some serious money, you have to know what each term means and how it works in you specific plan. If you have a group plan from your employer you are definitely paying much less than if on your own, but do you really know what that plan really says or what it offers? Some people are better off and covered more for their own private plan once they figure out the medical lingo.

The whole point of health insurance is to pay for the accumulating cost of exams, diagnostics, and treatments of any particular issue you may have. There are several coverage options when it comes to what kind of health care plan you have or want. Try to pick a plan that best meets you needs and budget, this will help you save money. Also, don’t feel dumb if you have no clue what your agent says. You can ask them what things mean if you don’t know. You are better able to understand what you are covered for than be surprised when you get the bill. It is better to know what is available to you in health benefits on all fronts. Become familiar with the types of plans available and know their specific advantages and disadvantages so you can best determine what works for you.

TYPES OF POLICIES:

●Indemnity Policies (Traditional Fee-for-Service Insurance)

●Preferred Provider Organizations (PPOs)

●Health Maintenance Organizations (HMOs or Managed Care)

●Self-Insured Health Plans (Single Employer Self-Insured Plans)

●Multiple Employer Welfare Arrangements (MEWAs)

HEALTH INSURANCE TERMS:

●Assignment of Benefits: Your signed authorization to give your doctor or hospital (medical provider) direct payment to them for your medical treatment. This means you do not see the money and don’t have to pay at the time of service more than your co-pay.

●Business Day: Every day that insurance companies are open for business, which excludes Saturday, Sunday, and state and federal holidays. These tend to be from Monday to Friday from 8-9 AM to 4-5 PM their local time.

●Calendar Day: Every day of the calendar month, which includes Saturday, Sunday, and state and federal holidays. If something happens on a Saturday, Sunday, or holiday you will be able to call in a claim but it will not be recorded till the next business day.

●Certificate of Coverage: The document you get that tells you that you are a member of the group and hold a policy.

●Certificate of Creditable Coverage: A written statement from your previous insurance company and/or health plan stating the length of time you were covered with them.

●Claim: A notification to your insurance company that payment is due under the policy provisions.

●Co-payment - The portion of charges you pay to your provider for covered health care services in addition to any deductible.

●Coverage: The actual details of protection provided by an insurance contract.

●Denial: An insurance company’s decision to withhold a claim payment or demand a preauthorization. A denial may be made because the medical service is not covered, not medically necessary, or experimental or investigational.

●Deductible: A set amount of money paid by the insured for medical costs before benefits kick in and pay.

●Exclusions and/or Limitations: Conditions or circumstances spelled out in an insurance policy that limit or exclude coverage benefits. It is important to read all exclusion, limitation, and reduction clauses in your health insurance policy or certificate of coverage to determine which expenses are not covered.

●Experimental and/or Investigational Medical Services: A drug, device, procedure, treatment plan, or other therapy, which is currently not within the accepted standards of medical care. These items are more than likely not covered.

●Grace Period: A specified period immediately following the premium due date during which a payment can be made to continue a policy without interruption. This applies only to Life and Health policies. Check your policy to be sure that a grace period is offered and how many days, if any, are allowed.

●Independent Medical Review: A process where expert medical professionals who have no relationship to your health insurance company or health plan review specific medical decisions made by the insurance company.

●Medically Necessary: A drug, device, procedure, treatment, or other therapy that is covered under your health insurance policy and that your doctor, hospital, or provider has determined essential for your medical well-being, specific illness, or underlying condition.

●Policy: The written contract between an individual or group policyholder and an insurance company. The policy outlines the duties, obligations, and responsibilities of both the policyholder and the insurance company. A policy may include any application, endorsement, certificate, or any other document that can describe, limit, or exclude coverage benefits under the policy.

Know your Health Insurance Rights during a Lay off

Providing health coverage for laid-off workers is good health policy for all employers. This can take away some of the sting from being out of work and COBRA payments. Tax credits for laid-off workers are also available and can be a valuable element of a phased-in national strategy to assist the uninsured. Laid-off workers can receive effective, temporary "bridge" coverage between jobs using the COBRA law. These benefits will be the same as with their employer but at a higher cost. There are advantages in targeting this on this group for helping. Providing health insurance to persons becoming unemployed will help keep these people on the map so to speak. One of the biggest problems with American health insurance after unemployment is the disappearance of it. Most uninsured Americans had health coverage at some recent point but then lost it, typically because of unemployment, or some other reasons, such as aging out of a parent's policy or wage in-creases that exceed public program limits.

Targeting these people for aid or assistance in lower premium insurance will help reduce the number of uninsured. And as suggested by many American public opinion polls, there is more than 90 percent public support for helping laid-off workers. This addresses an important worry in the 165 million Americans under age 65 who have employer-based insurance. They too are afraid that a pink slip could end their health insurance. Helping laid-off workers obtain health coverage, regard-Less of the cause of their unemployment, would also remedy an inequity created by the Trade Act. It is hard to justify covering unemployed workers whose lay-offs result from foreign competition while denying help to equally needy and hard-working Americans who are laid-off for other reasons.

Moreover, a simple tax credit targeted to those who lose who lose their jobs due to layoff would not risk unraveling or jacking up an employer’s group coverage. Some policymakers fear that such tax credits to assist the employed uninsured could cause some businesses to drop coverage. Also young, healthy workers could take up credits, leaving employers responsible for the higher-cost group left behind. If credits were limited to laid-off workers and not include working persons refusing health care plans, this would be anything to worry about. One national survey found that 52 percent of uninsured adults lost health coverage because they or a spouse lost their job. No other single cause of insurance loss was re-ported by more than 12 percent of uninsured adults. The only thing these people have to turn to is COBRA, which when unemployed can sometimes be impossible to pay for.

The federal Consolidated Omnibus Budget Reconciliation Act (COBRA) is for workers who lost health benefits through voluntary or involuntary job loss, reduction in work hours, or transition between jobs. This gives them the right to continue group health benefits through their current plan. COBRA requires that employers with 20 or more employees that offer group health plans must offer a temporary extension of health benefits. Under COBRA, employees, their spouses and dependent children are eligible to continue coverage for up to 18 months following lay-off or reduction in work hours. Employers are not required to pay for continuing coverage as the did when the person was employed with the company. The workers are responsible for the full price of the plan and may be required to pay up to 102% of the cost of the health plan

If your spouse or domestic partner is covered under employer-based coverage you and your dependent children may be eligible through that plan's dependent coverage. Again, employers are not required to pay for such coverage, and you may be required to pay the full cost of the health plan. For more information, contact your spouse or domestic partner's employer. The only problem with this option can be that you may have to wait till open enrollment to be able to change the policy. Some employers will only let changes to be made if there is a birth, death, divorce or marriage taken place. Other than that most have to wait 12-18 months for the next opportunity to add new people or change their benefits.

Private Health Insurance may be purchased by anyone directly from any company that deals with health plans. However, individual policies are generally priced higher than those through a group plan, and insurers can ask about your health history and may exclude "preexisting medical conditions," deny coverage, or charge less than healthy people a higher rate than they charge healthy people. For more information contact the health plan or insurance broker of your choice listed in the Yellow Pages under "Health Plans" and "Insurance." When deciding on a policy it is best to speak directly with an agent. Make sure you get several different opinions before deciding on a plan.

Medicaid Madness The Latest in Eligibility Requirements

Medicaid is state regulated and funded health insurance that helps low-income persons who can't afford medical care pay for some and/or all of their medical bills. If you qualify and don’t have medical insurance, Medicaid can help you stay healthy and assist you till you find other resources. Medicaid is available only to people with limited income and has strict limitations. In order to qualify, you must fall into a group of persons that meet specific criteria. Medicaid pays money directly to your health care providers. Depending on your state's rules, you may also be asked to pay a small part of the cost (co-payment) for some medical services or prescription drugs. .

Many groups of people can be covered under Medicaid that will qualify under their own group’s specific guideline. Some examples of group’s requirements can include your age, whether you are pregnant, disabled, blind, or aged or your income and resources. Resources can be cash or any item that can be sold for a substantial amount of money, or bank accounts, or property. Another requirement is whether you are a U.S. citizen or a lawfully admitted immigrant. The rules for counting your income and resources vary from state to state and from group to group, so you should check the requirements that pertain to where you are living.

In addition, for those persons living in a nursing home or at home with disabilities, there are specific rule and guidelines to be met. Your dependent child or children may be eligible for coverage if they are U.S. citizens or a lawfully admitted immigrant, even if you are not. Eligibility for children is based on the child's status, not the parent's. Also, if someone else's child lives with you, the child may be eligible even if you are not because your income and resources will not count for the child.

General eligibility requirements you must meet to obtain Medicaid in your state may vary from other states, but they are pretty mush based on the same criteria. You must meet the income, dependent, resources, and other various requirements asked on the application to qualify. People who qualify are individuals over 65, blind, and disabled for social security disability purposes. Others are families or single parents with children under 21 year old who either don’t make enough money, don’t have health benefits at a reasonable cost, or are on public assistance. Single and married persons with a temporary disability, limited income, special circumstance, or between the ages 59-64 also can meet the criteria. If you need to seek drug or alcohol treatment, or are the victim of domestic violence you are eligible for Medicaid during treatment and possibly after the crisis is over. You can also qualify if you are caring for a child or disabled person.

When applying for Medicaid your eligibility is determined by your income and that can come from various sources. They compare the income and to the size of the family to determine if they qualify. Qualifying income is, and not limited to, earned wages, interest, dividends, social security, veterans’ benefits, pensions, child support, and spouse or partner’s income if living with them. Types of payments that aren’t considered countable income are public assistance, social security benefits, food stamps, low income home energy assistance program benefits, foster care payments, certain housing and utility subsidies, and weatherization payments. There are income limits of course and they are strict, if you exceed them by a penny you don’t qualify. The limits are different depending on the amount of family members living in the home and requesting the benefits.

You will have to have proof of your resources and family size to determine if you have resource limits and are eligible. Different groups of qualifiers will vary in what resources they can have. Resource limits do not apply for those persons with children at home and under the age of 21. Resources that are counted in eligibility determination are cash, checking and/or saving accounts, certificates, Christmas or vacation clubs, stocks and bonds, some types of trust funds, life insurance, vehicles, revocable burial funds, and non-resident property. Items that cannot count against you when determining eligibility are your home, burial space and marker, and one vehicle per household. If you are a student and get federal grants and loans, those cannot be counted either.

Options for Those Who Cannot Afford Health Insurance

The high cost of health insurance is an American epidemic. It holds no bearing on what income class you are in, it is still too expensive. The most effected are the poor and middle classes. They have fewer options because they have less money to spend. Many of these people can barely afford any type of insurance and in some cases cannot afford any coverage at all. There are approximately over 40 million Americans that have no health insurance and the numbers are steadily rising. Many households have incomes less than $20,000 annually so affording insurance benefits is not an option. For low wage jobs or jobs that have less than 20 employees, benefits are very limited and sometimes not even offered.

In addition, most of the people who are uninsured don’t qualify for public medical assistance because the limits for not being eligible are extremely low. The growing population of self employed people who don’t have the option of group rate medical insurance also often go with out benefits due to the expensive nature of independent health care plans. They may seem to have more money but the total out of pocket and premium expenses add up at the end of the year when you have to pay taxes and overhead as well as regular bills.

It really doesn’t matter if you are an unskilled laborer or extremely skilled professional. If you lack a an employer health care plan at a reasonable cost, you only the two choices or no insurance or paying through the nose for a private plan. Many Americans just opt to be uninsured so they can pay for their regular bills and feed themselves and their families. How these people pay for their medical bills depends on their resources. Some people will qualify for public assistance and be able to get help with medical benefits similar to an HMO. For those who don’t qualify for public assistance, some people go to clinics that give care based on income. This offers decent care for a reasonable price. This option does not cover hospital or emergency care. You will have to make a payment arrangement with the hospital you chose. Then there the people who cannot even afford small payments and chose to go to the emergency room where they cannot be turned away, then not pay at all. This kind of thing is very common and just makes medical cost rise and makes health care and insurance even more costly.

Some of the reason for the growing cost in medicine today is due to the increasing demand for new and improved techniques and medicines. People are willing to shell out their entire savings for a new treatment or surgical technique. So the health care industry endorses these new expensive experiments and then refuses to cover them without upping the plan cost. It is extremely important for people to take their medical future seriously. But with rise in cost and decline in access and ability, it makes that very hard for many. Many companies are trying battle the cost of health care for their employees by setting up medical savings accounts. The employees can have a deduction from their check and put it in this account tax free and collect interest. Many people cannot afford to put money in the account even if it is offered though. Some employers offer a matching amount as an incentive for the investment. Unfortunately, the biggest advantage will be to the upper and wealthy class persons. The low income and working class will see little benefit from MRAs.

With the increase in unemployment there are a growing number of people who don’t have group insurance rate at their disposal. These people are either forced to pay for their old policy through COBRA at a much higher rate, buy a private policy at a high rate, or go with out medical benefits till they find work that will offer a plan. The poorest of Americans are the least heard about. The big business sweeps them under the carpet and pretends they aren’t there. For those people who are $1 over poverty guidelines, obtaining insurance is near impossible. Even applying for other types of public assistance with medical can take years of being on a waiting list. For these extremely poor folks, even a clinic is like paying $100 per visit.

Life and Health Insurance License Exam Cram

If you are studying for your life and health insurance licensing exam, we have the ultimate study tool for you. Life and Health Insurance License Exam Cram is a great resource to help you learn the concepts, laws, rate calculations and state and federal regulations that will be covered on the exam. You'll also receive a CD that includes a fully-customizable test engine, detailed score report and state-specific law supplement. No matter where you are taking your exam or which area you need to focus on during your studying, Life and Health Insurance License Exam Cram is your smartest way to get certified.

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Origins of American Health Insurance: A History of Industrial Sickness Funds (Yale Series in Economic and Financial History)

How did the United States come to have its distinctive workplace-based health insurance system? Why did Progressive initiatives to establish a government system fail? This book explores the history of health insurance in the United States from its roots in the nineteenth-century sickness funds offered by industrial employers, fraternal organizations, and labor unions to the rise of such group plans as Blue Cross and Blue Shield in the mid-twentieth century.

Historians generally view the failure to establish universal health insurance during the first half of the twentieth century as an indicator of the political clout of insurers, employers, unions, and physicians who thwarted Progressive efforts. But the explanation is actually simpler, John Murray contends in this book. Careful analysis of the workings of industrial sickness funds suggests that workers rejected plans for compulsory state insurance because they were largely content with existing private plans. Murray revises our understanding of the evolution of health care insurance in the United States and discusses the implications of that history for the ongoing debates of today.

Author: John E. Murray
Hardcover: 336 pages
Company: Yale University Press (2007-11-13)
ISBN: 0300120915
List Price: $40.00
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Pros and Cons of Supplemental Health Insurance

Supplemental insurance benefits, like cancer insurance or heart/stroke insurance are paid directly to the insured, unless otherwise required by Medicare supplemental insurance. Hospital and major medical insurance benefits are paid directly to the provider, which you would only have to pay small co-pay, if anything. But if an emergency were to happen or you had a specific disease or condition that was going to cost you out of pocket expenses, investing in a supplemental plan is a good idea. As a policyholder, you can use those benefits to help with your out-of-pocket expenses or loss of income. Supplemental insurance products such as cancer and accidental injury insurance are not a replacement for major medical insurance. These types of policies help to cover expenses that are not covered by major medical insurance and reduce the money paid out by the insured. These policies can also paid for lost income in the case of missing work.

Supplemental medical insurance only provides coverage after your regular medical insurance has been exhausted. Supplemental medical insurance is used to pick up where basic medical insurance leaves off. You will have to hold a regular health plan to be able to use the supplemental insurance. When this coverage is exhausted, your supplemental medical coverage would begin paying. Supplemental medical coverage is written in a separate policy, and does not include coverage for basic doctor visits. Supplemental insurances are definitely lifesavers for many people. The only downside is that they can be expensive and useless if you never need them. You have to pay for your regular medical coverage and now add an extra policy or two and that can get pretty high. If you try to purchase a policy after you have become ill or injured it won’t cover a pre-existing condition, so you will pay out and not receive and benefits for the condition you already have. The idea is that you have to buy into a supplemental plan prior to the incident so they can collect off of you being healthy. Here are some plans for supplementing your health insurance that can be used at any age.

Cancer Insurance provides benefits to help cover costs for cancer treatment and other related expenses associated with the disease. Most policies provide direct-to-policyholder cash benefits for daily hospitalization and intensive care unit confinement, as well as for surgery, anesthesia, chemotherapy, radiation, and preventative care. This is a good plan to have if you have a family history of cancer, it could save your life and your wallet.

Critical Condition/Critical Illness Insurance is a policy designed to provide you with a lump sum benefit to help pay out-of-pocket expenses if you suffer a heart attack, stroke, have heart surgery, cancer (except skin cancer) or several other conditions. It covers illnesses and diseases that cause you to hospitalized for critical condition and picks up where you regular benefits left off.

Disability Income Protection supplements lost income by paying a monthly benefit to you if you become partially or totally disabled due to a covered illness. This also provides a daily benefit for in-patient hospitalization for a covered illness. This policy has a reduction in benefits after age 65.

Hospital Emergency Recovery & Outpatient Insurance (Supplemental Medical) provides benefits for treatment due to a covered illness including daily benefits for in-patient hospitalization, intensive care and recovery care following hospital confinement due to a covered illness. It also provides a benefit for outpatient surgery and emergency room treatment for each covered illness.

Some of the plans geared toward the elderly and retiring persons are actually very smart to have. They can help pay for things that Medicare won’t or can’t. They also offer assistance if you ever need to be cared for at home, move to an assisted living home, or need to go to a nursing home. These types of expenses can leave other family members in debt after you are gone. Funeral and burial are usually also covered. This gives many folks the ability to leave their families something other than bills. Also with assistance for medication there is more money to enjoy while you are still around. Some age related supplemental insurances are:

Long Term Care Insurance can help cover the high cost of a variety of long-term care options such as: assisted living facilities, medical home care, custodial home care, adult day care, and if necessary, nursing home care, up to specified policy limits. Includes bed reservation benefit, respite and hospice care, emergency response system, and caregiver training. For an additional cost, you have the option of a valuable cost-of-living adjustment option. Separate Nursing Home Care and Home Health Care only policies also are available in most states. These will pay if you or your spouse needs to go into a nursing care facility.

Medicare Supplement Insurance is for people 65 and over mostly. These offer a wide range of standardized plans that supplement expenses not covered by Medicare. This will help pay for doctors visits and prescriptions that were only covered partially by Medicare.