A Medigap policy is a health insurance policy sold by private insurance companies to fill “gaps” in Original Medicare Plan coverage. Medigap policies must follow federal and state laws. These laws protect you. The front of the Medigap policy must clearly identify it as “Medicare Supplement Insurance.”
Each policy has a different set of benefits. Two of the standardized policies may have a high deductible option. In addition, any standardized policy may be sold as a “Medicare SELECT” policy. Medicare SELECT policies usually cost less because you must use specific hospitals and, in some cases, specific doctors to get full insurance benefits from the policy. In an emergency, you may use any doctor or hospital.
Click image to view guide to Medigap Policies
Outline of Medicare Supplement Coverage
(Benefit Plans A-N)
This chart shows the benefits included in each plan. Every company must make available Plan “A”. Some plans may not be available in your state as indicated below.
Plans A-N is standardized by the federal government. Not all plans may be available in your area. Consider the benefits offered by each plan and look for one that best meets your individual needs.
*Medigap Plan F also offers a high-deductible plan. This means you must pay for Medicare-covered costs up to the deductible amount before your Medigap plan pays anything.
**After you meet your out-of-pocket yearly limit and your yearly Part B deductible, the plan pays 100% of covered services for the rest of the calendar year. The out-of-pocket limit is the maximum amount you would pay for coinsurance and copayments.
***Plan N pays 100% of the Part B coinsurance except for a small copayment for office visits and emergency department visits.
Employers must issue an annual notice of Medicare Part D to employees, see more.
Learn more about Medicare options for both, individuals and groups. We are successfully helping navigate SMB for 20+ years. Please contact us at 855-667-4621 or info@medicalsolutionscorp.com.
What is Long Term care? Insurance is an important tool for protecting yourself against risk. For instance, health insurance pays your doctor and hospital bills if you get sick or injured. But how can you protect yourself against the significant financial risk posed by the potential need for long-term care services, either in a nursing home or in your own home?
Long-term care goes beyond medical care and nursing care to include all the assistance you could need if you ever have a chronic illness or disability that leaves you unable to care for yourself for an extended period of time. You can receive long-term care in a nursing home, assisted living facility, or in your own home. Though older people use the most long-term care services, a young or middle-aged person who has been in an accident or suffered a debilitating illness might also need long-term care.
Beyond nursing homes, there is a range of services available in the community to help meet long-term care needs. Visiting nurses, home health aides, friendly visitor programs, home-delivered meals, chore services, adult daycare centers, and respite services for caregivers who need a break from daily responsibilities can supplement care given by family members.
Are you likely to need long-term care? You may never need long-term care. But about 19 percent of Americans aged 65 and older experience some degree of chronic physical impairment. Among those aged 85 or older, the proportion of people who are impaired and require long-term care is about 55 percent. By the year 2020, 12 million older Americans will need long-term care. Most will be cared for at home; family members and friends are the sole caregivers for 70 percent of elderly people. But a study by the U.S. Department of Health and Human Services indicates that people age 65 face at least a 40 percent lifetime risk of entering a nursing home. About 10 percent will stay there five years or longer.
The American population is growing older, and the group over age 85 is now the fastest-growing segment of the population. The odds of entering a nursing home, and staying for longer periods, increase with age. In fact, statistics show that at any given time, 22 percent of those age 85 and older are in a nursing home. Because women generally outlive men by several years, they face a 50 percent greater likelihood than men of entering a nursing home after age 65.
While certainly older people are more likely to need long-term care, your need for long-term care can come at any age. In fact, the U.S. Government Accountability Office estimates that 40 percent of the 13 million people receiving long-term care services are between the ages of 18 and 64.
What do policies cost? The cost of long-term care insurance varies widely, depending on the options you choose. For example, inflation adjustments can add between 40 and more than 100 percent to your premium. However, this option can keep benefits in line with the current cost of care.The actual premium you will pay depends on many factors, including your age, the level of benefits, and the length of time you are willing to wait until benefits begin. A licensed long-term care insurance agent or a financial advisor can help in balancing policy features and premium cost.
Age In 2002, a policy offering a $150 per day long-term care benefit for four years, with a 90-day deductible, cost a 50-year-old a national average of $564 per year. For someone who was 65 years old, the national average cost was $1,337, and for a 79-year-old, the national average cost was $5,330. The same policy with an inflation protection feature cost, on average nationally, $1,134 at age 50, $2,346 at age 65, and $7,572 at age 79. Please note that these are only national averages. The cost of long-term care varies significantly by state. For the cost of care and coverage in your area, check with a representative of a long-term care insurer, an insurance agent, or financial adviser.Premiums generally remain the same each year (unless they are increased for an entire class of policyholders at once). That means that the younger you are when you first buy a policy, the lower your annual premium will be.
Benefits The amount of your premium also depends on the amount of the daily benefit and how long you wish that benefit to be paid. For example, a policy that pays $100 a day for up to five years of long-term care costs more than a policy that pays $50 a day for three years.
Elimination or deductible periods Elimination or deductible periods are the number of days you must be in residence at a nursing home or the number of home care visits you must receive before policy benefits begin. For instance, with a 20-day elimination period your policy will begin paying benefits on the twenty-first day. Most policies offer a choice of deductible ranging from zero to 180 days. The longer the elimination or deductible period, the lower the premium. However, longer elimination periods also mean higher out-of-pocket costs. For instance, if have a policy with a 100-day waiting period and you go to a nursing home for a year, you must pay for 100 days of care. If your stay costs $150 a day, your total cost would be $15,000. With a 30-day elimination period, your cost would be only $4,500.
When you’re considering a long-term care policy, you should determine, not just how much you can pay for premiums but also how long you could pay for your own care. Bear in mind that while 45 percent of nursing home stays last three months or less, more than one-third last one year or longer. The more costly longer stay may be the devastating financial blow that you may want to insure against.
Where can I get long-term care coverage? Although long-term care insurance is relatively new, more than 100 companies now offer coverage.Long-term care insurance is generally available through groups and to individuals. Group insurance is typically offered through employers, and this type of coverage is becoming a more common benefit. By the end of 2002, more than 5,600 employers were offering a long-term care insurance plan to their employees, retirees, or both.
Individual long-term care insurance coverage is a good option if you are not employed, work for a small company that doesn’t offer a plan, or are self-employed. Choosing a policy requires careful shopping because coverage and costs vary from company to company and depend on the benefit levels you choose.
New York Long Term Care Insurance Partnership Program
TheNew York State Partnership for Long Term Care is a partnership program between private insurance companies and Medicaid to finance Long Term Care of the people of the State of New York. Medicaid program under the Partnership is known as Medicaid Extended Coverage. Under the Partnership program, New Yorkers may be able to apply for Medicaid assistance without exhausting their assets and resources. Medicaid Extended Coverage allows eligible policyholders to protect all of their assets through Total Asset Protection Plan, or some, through Dollar for Dollar Asset Protection Plan. With these alternatives, New Yorkers are assured of their continued care after using up the benefits provided by their private insurance policies, without losing their life savings and their dignity.
Region
Home Health Aide Hourly Rate (Medicare Certified)
Assisted Living Facility Monthly Rate (Private room)
Nursing Home Daily Rate (Semi-private room)
Nursing Home Daily Rate (Private room)
Albany – Schenectady – Troy
$23
$3,723
$304
$315
Binghamton
$21
$5,078
$280
$290
Bronx
$16
$2,045
$382
$382
Brooklyn
$18
$1,850
$340
$343
Buffalo – Niagara Falls
$23
$3,633
$301
$305
Elmira
$21
$2,965
$313
$317
Glens Falls
$23
$2,828
$270
$281
Ithaca
$22
$5,440
$250
$263
Kingston
$20
$3,231
$354
$362
Long Island
$22
$3,800
$398
$388
Manhattan
$19
$1,720
$438
$459
Outer New York City Area
$21
$6,000
$325
$358
Poughkeepsie – Newburgh – Middletown
$24
$3,800
$357
$367
Queens
$17
$4,000
$331
$336
Rochester
$24
$3,788
$305
$325
Staten Island
$19
$2,225
$310
$325
Syracuse
$20
$2,750
$270
$270
Utica – Rome
$19
$2,344
$235
$250
Rest of State
$23
$2,200
$251 $258
Long Term Care Partnership Policies
All insurance companies participating in the Partnership program must include the following basic benefits in the policies that they offer:
Nursing home care
Nursing home bed reservation of 20 days per year
Skilled nursing care
Assisted living care
Adult care
Home care
Personal care
Respite care (14 nursing home equivalent days per year)
Hospice care
Alternate level of care – in-patient services received in a hospital while waiting to be placed in a nursing home, or while waiting for arrangements for home care.
Care management – minimum of 2 consultations per calendar year. This is a face-to-face care management consultation done by independent healthcare professionals, to assess the services received by a policyholder and give recommendations to optimize utilization of insurance benefits. Care management benefits depend on the amount of the nursing home daily benefit. For instance, if a policyholder has a $300 nursing home daily benefit, his care management benefits would amount to $600 for one calendar year. If one care management consultation costs $200, then a total of three consultations can be accessed for a year. However, care management benefits, if used, are deducted from the maximum lifetime benefits that a policyholder may receive.
Inflation protection of 5% compounded annually – Partnership policies issued to qualified policyholders aged 79 and below include a 5% annual compounded inflation protection. This benefit is optional to those aged 80 and above.
Guaranteed renewable – the insurance company cannot decline should a policyholder wishes to renew a policy, provided that the policyholder pays the premium on time and makes no changes in the provision of the Partnership policy while it is in force.
Partnership Independent Assessment Benefit – a unique feature of Partnership policies. This allows policyholders who are denied by their Partnership insurance company of benefits (due to failure to meet disability standards) to request for an independent review by the New York State Partnership office.
Additional benefits may be offered by some participating insurance companies but with additional costs in policy premiums. Examples are waiver of premium (payment of premium is waived after care has started), combined home care benefit, independent provider benefit, etc.
Types of Partnership Policies in the New York Long Term Care Partnership Program
1. Total Asset 50 – minimum 3 years Nursing home care OR 6 years Home care with a minimum daily benefit of $218 for Nursing home and $109 for Home care.
2. Total Asset 100 – minimum 4 years Nursing Home care OR 4 years Home care OR 4 years Residential Care Facility. The minimum daily benefit of $218 is provided for Nursing Home and $218 for Home care.
Both Total Asset 50 and Total Asset 100 can have unlimited maximum policy duration and 100 days maximum elimination period.
3. Dollar for Dollar 50 – minimum 1.5 years Nursing home care OR 3 years Home care and maximum 2.5 years Nursing Home or 5 years Home Care. Minimum daily benefits are $218 for Nursing home and $109 for Home care.
4. Dollar for Dollar 100 – minimum 2 years Nursing Home care OR 2 years Home care OR 2 years Residential Care Facility and maximum of 2.5 years for the aforementioned care settings. The minimum daily benefit of $218 is provided for Nursing Home and $218 for Home care.
Both Dollar for Dollar 50 and Dollar for Dollar 100 Plans have 60 days elimination period.
Obtaining a Partnership Policy in New York
Applicants go through an assessment process and must satisfy requirements in order to qualify to the Partnership program. The New York State office does not sell Partnership policies. The New York State Department of Insurance authorizes private insurance companies to market Partnership policies. Below is a list of participating insurance companies:
For individual policies:
Genworth Life Insurance Company of New York
John Hancock Life Insurance Co.
MedAmerica Insurance Co. of New York
Metropolitan Life Insurance Company
New York Life Insurance Company
For group policies:
CNA Insurance Companies (NYC Employees Only)
MedAmerica Insurance Co. of NY
MedAmerica Insurance Co. of NY (NYS Employees and Retirees Only)
Metropolitan Life Insurance Company (NYSUT Members Only)
Prudential Insurance Company (AICPA Members Only)
The New York State Partnership for Long Term Care has no reciprocity agreement. Therefore if you move to another state, you must come back to New York State and be a resident to be eligible for the Medicaid Extended Coverage part of your Partnership policy.
For more information, you may contact the toll-free New York State Medicaid Helpline at 1-800-541-2831 or the Human Resources Administration at 1-877-472-8411 for NYC residents (5 Boroughs).
Can I move out of NY and use this? Your Partnership policy has two components: a private insurance component and the Medicaid Extended Coverage component. During the private component, you can use your policy’s benefits wherever you choose (in accordance with the policy contract conditions). During the Medicaid Extended Coverage component, you must be a New York State resident in order to receive New York State Medicaid Extended Coverage.
Millennium Medical Solutions Corp is trained and certified to offer NYS Partnership for LTC.
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Most of the expenses below qualify as a tax-free withdrawal from your HSA, unless the expenses were reimbursed by your health care coverage. The following list is provided as reference only and is not meant to be comprehensive. For a complete list of qualified expenses see IRS Publication 502. To orderIRS Publication 502, call 1-800-TAX-FORM. Or visit their websitewww.irs.gov
Abortion
Acupuncture
Alcoholism Treatment
Ambulance
Artificial Limb
Artificial Teeth
Birth Control Pills
Blood Donor Expenses
Braille Books & Magazine
Capital Expenses
Chiropractor Fees
Christian Science Practitioner
COBRA Payments
Contact Lenses
Coinsurance
Crutches
Deductible
Dentist Fees
Diagnosis
Diathermy
Drugs (legal, prescription, or insulin)
Elastic hose, medically prescribed
Eyeglasses
Eye Examination
Examination, physical
Fertility Enhancement
Gynecologist
Halfway House Residency
Hearing Devices
Home Medical Equipment
Hospital Fees
Laboratory Fees
Laser and other Eye Correction Surgery Products
Lip Reading Lessons for the deaf
Long Term Care and Premiums
Massage, Other Medically-Necessary
Manipulative Therapies
Meals
Medical Information Plan
Midwife
Nursing Care Obstetrician Obstetrical Expenses
Operations and Related Treatments
Ophthalmologist Optician
Optometrist Oral Surgery Organ Donors
Orthodontia Osteopath
Oxygen and Equipment
Pediatrician Physician
Fees Physiotherapist
Podiatrist Prosthesis
Psychoanalyst
Psychologist
Rental of Medical or Healing Equipment Seeing
Eye Dog or Other Animal Special Education for
Handicapped Individuals Sterilization
Stop Smoking Programs Substance Abuse
Treatment Support or Corrective Devices
(including Special Mattress and Board for Arthritis Surgeon
Telephone For The Deaf Television Set
Modifications to Receive Closed Captions
Therapy Treatments
Transplants
Transportation Expenses Relative to Illness
Tuition Vasectomy
Weight-Loss Program (Prescribed)
Wheelchair X-Ray
Accountable Care Organization (ACO) – These organizations coordinate patient care and provide the full range of health care services for patients. The health reform law provides incentives for providers who join together to form such organizations and who agree to be accountable for the quality, cost, and overall care of Medicare beneficiaries who are enrolled in the traditional fee-for-service program who are assigned to the ACO. Annual Benefit Limit – In the past, some insurance plans have placed a limit on the dollar amount of claims they will pay in a given year for an individual. Beginning in 2010, annual benefit limits on certain “essential health benefits” are restricted on a graduated basis, and annual limits will eventually be prohibited in 2014. Basic Health Plan – Beginning in 2014, states will have the option of creating a basic health plan to provide coverage to individuals with incomes between 133 and 200 percent of poverty instead of enrolling in the health insurance exchange and receiving premium subsidies. The federal government will provide states that choose to offer this plan with 95 percent of what it would have paid to subsidize these enrollees in the health insurance exchange. Benefit Package – The set of health services, such as physician visits, hospitalizations, and prescription drugs, that are covered by a member’s insurance policy or group health plan. Capitation – Under a capitation system health care providers are paid a set amount for each enrolled person assigned to that physician or group of physicians, whether or not that person seeks care. Case Management – The coordination of medical care for patients with specific diagnoses or high health care needs, performed by case managers who can include medical directors or nurses. Catastrophic Coverage – A coverage option with a limited benefit plan design accompanied by a high Deductible. The plan design is intended to protect primarily against the cost for unforeseen and expensive illnesses or injuries. These plans are attractive to young adults in relatively good health. CHIP – The Children’s Health Insurance Program (CHIP) is a program administered by the United States Department of Health and Human Services that provides matching funds to states for health insurance to low income families with children. The program was designed with the intent to cover uninsured children in families with incomes that are modest but too high to qualify for Medicaid. Chronic Care Management – The coordination of health care and supportive services to improve the health status of patients with chronic conditions, such as diabetes and asthma. The goals of these programs are to improve the quality of care and manage costs. COBRA – Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA) applies to employers who generally employ 20 or more full time equivalent employees. Employees who lose their jobs are able to continue their employer-sponsored coverage for a set period of time. For example, employees are typically entitled to extend coverage for 18 months, however if they are deemed disabled by the Social Security Administration, coverage may continue for up to 29 months. Co-insurance – The amount or percentage of the reimbursed amount of covered expenses a plan member must pay for health services after the Deductible has been met. Community Living Assistance Services and Supports (CLASS) Program – The CLASS program establishes a national voluntary long-term care insurance program for the purchase of non-medical services and support necessary for enrollees who have paid premiums into the program and become eligible (due to disability or chronic illnesses). Enrollees would receive benefits that help pay for assistance in the home or in a facility in future years. Enrollment begins January 1, 2011 (targeting working adults who can make voluntary premium contributions through payroll deductions or directly). The first benefits will be paid out to enrollees in 2016. Community Rating – A method of pricing health insurance plans, where all policyholders are charged the same premium, regardless of health status, age or other factors. “Modified community rating” generally refers to a method where health insurers may vary premiums based on specified demographic characteristics (e.g. age, gender, location), but cannot vary premiums based on the health status or claims history of policyholders. Comparative Effectiveness Research – Research is federally sponsored to compare existing health care interventions to determine which work best for which patients and which pose the greatest benefits and harms. The research also aims to improve the quality of care and to control costs. Consumer-Directed Health Plans – These health plans seek to increase consumer awareness about health care costs and provide incentives for consumers to consider costs when making health care decisions. These plans usually have a high Deductible accompanied by a savings account for health care services. There are two types of savings accounts – Health Savings Accounts (HSAs) and Health Reimbursement Accounts (HRAs). Co-payment – A fixed dollar amount paid by an individual receiving a health care service covered by the member’s plan. Cost-Sharing – Health plan members are required to pay a portion of the costs of their care. Examples of these costs include Co-payments, Co-insurance and annual Deductibles. Deductible – The dollar amount that a plan member must pay for health care services each year before the insurer begins to reimburse for health care services. Beginning in 2014, deductibles for small group insurance plans will be limited to $2,000 for individual policies and $4,000 for family policies. Disease Management – The coordination of care for the entire disease treatment process, including preventive care, patient education and outpatient care in addition to inpatient and acute care. The process is intended to reduce costs and improve the quality of life for an individual with a chronic condition. Donut Hole – A gap in prescription drug coverage under Medicare Part D, where beneficiaries pay 100% of their prescription drug costs after their total drug costs exceed an initial coverage limit until they qualify for a second tier of coverage. Under the standard Part D benefit, Medicare covers 75% of drug costs below the initial coverage limit ($2,830 in 2010), and 95% of spending within the second tier level ($6,440 in 2010). The “donut hole” specifically refers to the range between these two levels. Health care reform also provides a $250 rebate for all Medicare Part D enrollees who enter the donut hole in 2010, increases discounts in subsequent years and completely closes the donut hole by 2020. Dual Eligibles – A term used to describe an individual who is eligible for Medicare and for some Medicaid benefits.
Electronic Health Record/Electronic Medical Records – Computerized patient health records, including medical, demographic, and administrative information. These records can be created and stored within one organization or shared across multiple health care organizations and sites. Employee Retirement Income Security Act of 1974 (ERISA) – Enacted in 1974 to provide minimum Federal standards for welfare benefit plans in private industry, and protect the interests of employee benefit plan participants and their beneficiaries by requiring the disclosure to them of financial and other information concerning the plan; by establishing standards of conduct for plan fiduciaries; and by providing for appropriate remedies and access to the Federal courts. Employer Mandate – Beginning in 2014 pursuant to the health reform law, employers meeting size or revenue thresholds will be required to offer minimum essential health benefit packages or pay a set portion of the cost of those benefits for use in the Exchanges. Episode of Care – Refers to all the health services related to the treatment of a condition. For acute conditions (such as a concussion or a broken bone), the episode includes all treatment and services from the onset of the condition to its resolution. For chronic conditions (such as diabetes), the episode refers to all services and treatments received over a given period of time. Some payment reform proposals involve basing provider payment on episodes of care instead of paying on a Fee-for-Service basis. Essential Health Benefits – The health reform law placed certain coverage requirements on essential health benefits, and provides a broad set of benefit categories that would be considered essential to a health benefits package — including hospitalization, outpatient services, emergency care, prescription drugs, maternity care, preventive services and other benefits. The Secretary of HHS will, in the future, define what constitutes “Essential Health Benefits” and this will be guided by the current scope of benefits provided under a typical employer plan. For plan years beginning in 2010 the only requirement for “Essential Health Benefits” is that if they are included in the plan they may not be subject to a lifetime limit and until 2014 can only be subject to a “restricted annual limit”. Exchange or Health Insurance Exchange – The health care reform law creates Health Benefit Exchanges (competitive insurance marketplaces) in each state, where individuals and employers can shop for health plans. External Review – Health care reform requires all health plans (except Grandfathered plans) to provide an external review appeal process that meets minimum standards. With the exception of a few state processes currently in existence, external review has typically been limited to appeals of clinical decisions. The health reform law has expanded the scope of external review for self-funded health plans to non-eligibility administrative appeals as well. Administrative appeals deal with such issues as benefit exclusions, benefit limits and disputes over member financial responsibility for payments such as Co-payments, Co-insurance and Deductibles. Fee-for-Service – A traditional method of paying for medical services where doctors and hospitals are paid a fee for each service they provide.
FTE – Full Time Equivalent -The percent of time worked is based on a standard of 100% or 1.0. For example, an employee who is working 60% and employee who is working 40% of the time would equal 100% or an FTE of 1.0.
For example, a firm has 35 full-time employees (30+ hours). In addition, the firm has 20 part time employees who all work 24 hours per week (96 hours per month). These part-time employees’ hours would be treated as equivalent to 16 full-time employees, based on the following calculation: 20 employees x 96 hours / 120 = 1920 / 120 = 16
Grandfathered Plan – A health plan that was in place on March 23, 2010, when the health reform law was enacted, is exempt from complying with some parts of the health reform law, so long as the plan does not make certain changes (such as eliminating or reducing benefits, increasing cost-sharing, or reducing the employer contribution toward the premium). Once a health plan makes such a change, it becomes subject to other health reform provisions (e.g., appeals and cost sharing restrictions on preventive services).
Group Health Plan – Health insurance that is offered by a plan sponsor, typically an employer on behalf of its employees. Guarantee Issue/Guarantee Renewability – Beginning in 2014, the health reform law requires insurers to offer and renew coverage to non-Grandfathered plans, without regard to health status, use of services, or pre-existing conditions. Health Insurance Portability and Accountability Act of 1996 (HIPAA) – This law sets standards for the security and privacy of personal health information. In addition, the law makes it easier for individuals to change jobs without the risk of extended waiting periods due to pre-existing conditions. Health Maintenance Organization (HMO) – A health plan that provides coverage through a network of hospitals, physicians and other health care providers. HMOs usually require the selection of a primary care physician who is responsible for managing and coordinating all health care. Usually, referrals to specialist physicians are required, and the HMO pays only for care provided by an in-network provider. Health Reimbursement Account (HRA) – A tax-exempt account that can be used to pay for qualified health expenses. HRAs are usually paired with a high-Deductible health plan and are funded solely by employer contributions. Health Savings Account (HSA) – A tax-exempt savings account that can be used to pay for qualified medical expenses. Individuals can obtain HSAs from most financial institutions, or through their employer. Both employers and employees can contribute to the plan. To open an HSA, an individual must have health coverage under an HSA-qualified high-Deductible health plan which has Deductibles of at least $1,200 for an individual and $2,400 for a family in 2010. High-Deductible Health Plan – These health insurance plans have higher Deductibles and lower premiums than traditional insurance plans. High-Risk Pool – The health reform law expands upon the current state-based high-risk pool system. The law requires the government to establish or issue contracts to establish a temporary high risk pool (through 2013) to provide coverage for eligible individuals with pre-existing conditions by appropriating $5 billion to subsidize premiums. Eligibility is limited to individuals who have been uninsured for at least six months prior to applying for pool coverage, and who have a pre-existing condition. Individual Mandate – A requirement that most individuals obtain health insurance or pay a penalty beginning in 2014. Massachusetts was the first state to impose an individual mandate that all adults have health insurance. Interim Final Rule (IFR) – A final rule that has the full force and effect of law; thus, affected parties have an obligation to comply with its requirements. An IFR allows interested parties to submit comments during a public comment period and prior to issuing revised guidance. Internal Review – An internal review of an adverse claim determination. Lifetime Benefit Maximum – A limit on the amount an insurer will pay toward the cost of health care services over the lifetime of the policy. Health care reform prohibits lifetime dollar limits on “essential health benefits” effective for plan/policy years beginning on or after September 23, 2010. Long-Term Care – Services needed for an individual to live independently in the community, such as home health and personal care, as well as services provided in institutional settings such as nursing homes. Many of these services are not covered by Medicare or private insurance (see also the Community Living Assistance Services and Supports program defined above). Managed Care – A health care delivery system that seeks to reduce the cost of providing health benefits and improve the quality of care. These arrangements often rely on primary care physicians to manage the care their patients receive.
Mandatory Benefits – A state or federal requirement that health plans provide coverage for certain benefits, treatment or services. Medicaid – A federal and state funded program that provides medical and health related services to certain low-income Americans. The health reform law expands Medicaid eligibility to non-Medicare eligible individuals with incomes up to 133% of the Federal poverty level, establishing uniform eligibility for adults and children across all states by 2014. Medical Loss Ratio (MLR) – The minimum percentage of premium dollars a commercial insurance company must spend on the reimbursement of certain medical costs. The health reform law requires insurers in the large group market to have an MLR of 85% and insurers in the small group and individual markets to have an MLR of 80% (with some waivers granted to states to reduce the threshold for certain markets). Medicare – A federal program that provides health care coverage to people age 65 and older, and to those who are under 65 and are permanently physically disabled or who have a congenital physical disability; or to those who meet other special criteria such as end-stage renal disease. Eligible individuals can receive coverage for hospital services (Medicare Part A), physician based medical services (Medicare Part B) and prescription drugs (Medicare Part D). Medicare Advantage – Also referred to as Medicare Part C, the Medicare Advantage program allows Medicare beneficiaries to receive their Medicare benefits through a private insurance plan. Out-of-Pocket Costs – Health care costs that are not covered by insurance, such as Deductibles, Co-payments, and Co-insurance. Out-of-pocket costs do not include premium costs. Out-of-Pocket Maximum – An annual limit on the amount of money individuals are required to pay out-of-pocket for health care costs, excluding premiums. The health reform law, beginning in 2014, prevents an employer from imposing cost sharing in amounts greater than the current out-of-pocket limits for high-Deductible health plans ($5,950 for an individual policy or $11,900 for a family policy in 2010). These amounts will be adjusted annually. Patient Centered Medical Home – A term defining a health care setting where patients receive comprehensive primary care services, have an ongoing relationship with a primary care provider who directs and coordinates their care; and have enhanced access to non-emergent care. Patient Protection and Affordable Care Act (PPACA) – Also referred to as the “health reform law,” this Act begins the implementation of a staged set of rules with an initial effective date of March 23, 2010. The law is intended to increase access to health care for more Americans, and includes many changes that impact the commercial health insurance market, Medicare and Medicaid. Pay for Performance – A payment system where health care providers receive incentives for meeting or exceeding quality and cost benchmarks. Some systems also penalize providers who do not meet established benchmarks. The goal of pay for performance programs is to improve the quality of care over time. Pre-existing Condition – An illness or medical condition for which a person is diagnosed or treated within a specified period of time prior to becoming insured in a new plan. The heath reform law prohibits the denial of coverage due to a pre-existing condition for plan and policy years beginning after September 23, 2010 for children under 19, and for all others beginning in 2014. Preferred Provider Organization (PPO) – A type of managed care organization that provides health care coverage through a network of providers. Plan members typically pay higher costs when they seek care from out-of-network providers. Premium – The amount paid, often on a monthly basis, for health insurance. The cost of the premium may be shared between employers or government purchasers, and individuals. Premium Subsidies – A fixed amount of money, or a designated percentage of the premium cost, that is provided to help people purchase health insurance. The health reform law provides premium subsidies to individuals with incomes between 133% and 400% of the federal poverty level who purchase policies through the health insurance Exchanges, beginning in 2014. Preventive Care Services – Health care that emphasizes the early detection and treatment of disease. The health reform law requires certain health plans (excludes Grandfathered plans) to provide coverage without member cost-sharing for certain preventive services. Primary Care Provider – A provider, usually a physician, specializing in internal medicine, family practice, or pediatrics, who is responsible for providing primary care and coordinating other necessary health care services for patients. Qualified Health Plan – Insurance plans that are sold through a Health Insurance Exchange must have been certified as meeting a minimum benchmark of benefits (i.e., essential health benefits) under the health reform law. Rate Review – Review by insurance regulators of a health plan’s proposed premium and premium increases. Rates are reviewed to ensure they are sufficient to pay claims, are not unreasonably high in relation to the medical claim costs and the benefits provided, and are not discriminatorily applied. Reinsurance – Insurance purchased by insurance companies and employers that self-insure their employees’ medical costs, to limit liability or exposure to high claims or increased cost trends. The health reform law includes a temporary federal reinsurance program for employers that insure early retirees over age 55 who are not eligible for Medicare. Rescission – Refers to a practice where an approved policy is voided from its inception by the insurer, usually on the grounds of material misrepresentation or omission on the initial application. Under health reform, rescissions are prohibited except in cases of fraud or intentional misrepresentation. Risk Adjustment – The process of increasing or reducing payments to health plans to reflect higher or lower than expected spending. Risk adjusting is designed to compensate health plans that enroll a sicker population as a way to discourage plans from selecting only healthier individuals. Section 125 Plan – These plans are otherwise known as a “cafeteria plan” offered pursuant to Section 125 of the Internal Revenue Code. Its name comes from a set of benefit plans that allows employees to choose between different types of benefits, similar to the ability of a customer to choose among available items in a cafeteria, and the employees’ pretax contributions are not subject to federal, state, or Social Security taxes. Self-Insured Plan – The employer assumes the financial responsibility of health care benefits for its employees in a self-insured or self-funded plan. Employer sponsored self-insured plans typically contract with a third-party administrator to provide administrative services for the plan. Small Business Tax Credit – The health reform law includes a tax credit equal to 50 percent (35 percent in the case of tax-exempt eligible small employers) for qualified small employers that provide health coverage to their employees. The tax credit is available to employers with 25 or fewer employees with average annual wages of less than $50,000. Small Group Market – Businesses with typically 2-50 employees, or eligible employees depending on applicable state law, can purchase health insurance for their employees through this market, which is regulated by states. Tax Credit – An amount that a person or business can subtract from the income tax that they owe. If a tax credit is refundable, the taxpayer can receive a payment from the government to the extent that the credit is greater than the amount of tax they would otherwise owe. Tax Deduction – An amount that a person can subtract from adjusted gross income when calculating the taxes that they owe. Generally, people who itemize deductions can deduct the portion of medical expenses, including health insurance premiums, that exceeds 7.5% of their adjusted gross income. Under health reform, the threshold for deducting medical expenses increases to 10% in 2013 (this increase is waived for individuals 65 and older for tax years 2013-2016). Value-Based Purchasing – A payment reform which provides bonuses to hospitals and other providers based upon their performance against quality measures. Wellness Plan/Program – An employer program to improve health and prevent disease
A method of paying medical providers through a pre-paid, flat monthly fee for each covered person. The payment is independent of the number of services received or the costs incurred by a provider in furnishing those services.
COBRA
The Consolidated Omnibus Budget Reconciliation Act 1985, commonly known as COBRA, requires group health plans with 20 or more employees to offer continued health coverage for you and your dependents for 18 months after you leave your job. Longer durations of continuance are available under certain circumstances. If you opt to continue coverage, you must pay the entire premium, plus a two percent administration charge.
Coinsurance
The amount you are required to pay for medical care in fee-for-service plan or preferred provider organization (PPO) after you have met your deductible. The coinsurance rate is usually expressed as a percentage of billed charges. For example, if the insurance company pays 80 percent of the claim, you pay 20 percent.
Co-payment
A cost sharing arrangement in which a person pays a specific charge for a specific medical service — say $10 for an office visit or $5 for a prescription.
Deductible
The amount of money you must pay upfront each year to cover your medical care expenses before your insurance policy starts paying.
Exclusions
Specific conditions or circumstances for which the policy will not provide benefits.
Fee-for-Service
A payment system for health care where the provider is paid for each service rendered.
The percent of time worked is based on a standard of 100% or 1.0. For example, an employee who is working 60% and employee who is working 40% of the time would equal 100% or an FTE of 1.0
For example, a firm has 35 full-time employees (30+ hours). In addition, the firm has 20 part time employees who all work 24 hours per week (96 hours per month). These part-time employees’ hours would be treated as equivalent to 16 full-time employees, based on the following calculation:
20 employees x 96 hours / 120 = 1920 / 120 = 16
Health Maintenance Organization (HMO)
Prepaid health plans in which you pay a monthly premium and the HMO covers your doctor’s visits, hospital stays, emergency care, surgery, preventive care, checkups, lab tests, X-rays, and therapy. You must choose a primary care physician who coordinates all of your care and makes referrals to any specialists you might need. In an HMO, you must use the doctors, hospitals and clinics that participate in your plan’s network.
Health Savings Accounts (HSA)
An HSA works like an IRA, except that money is used to pay health care costs. Participants enroll in a relatively inexpensive high deductible insurance plan. Then, a tax-deductible savings account may be opened to cover current and future medical expenses. The money deposited, as well as the earnings, is tax-deferred. The money can then be withdrawn to cover qualified medical expenses tax-free. Unused balances roll over from year to year.
Lifetime Limit
A cap on the benefits paid under a policy. Many policies have a lifetime limit of $1 million, which means that the insurer agrees to cover up to $1 million in covered services over the life of the policy.
Managed Care
An organized way to manage costs, use, and quality of the health care system. The major types of managed care plans are health maintenance organizations (HMOs), point-of-service (POS) plans and preferred provider organizations (PPO).
Medicaid
A joint federal-state health insurance program that is run by the states and covers certain low-income people (especially children and pregnant women), and disabled people.
Medicare
The federally sponsored health insurance program of hospital and medical insurance primarily for people age 65 and over.
Out-of-Pocket Maximum
The most money you will be required to pay in a year for deductibles and coinsurance. It is a stated dollar amount set by the insurance company, in addition to regular premiums.
Point-of-Service (POS) Plan
A type of managed care plan combining features of health maintenance organizations (HMOs) and preferred provider organizations (PPOs), in which individuals decide whether to go to a network provider and pay a flat dollar copayment (say $10 for a doctor’s visit), or to an out-of-network provider and pay a deductible and/or coinsurance charge.
Portability
The ability for an individual to transfer from one health insurer to another health insurer with regard to pre-existing conditions or other risk factors.
Pre-authorization
A cost containment feature of many group medical policies whereby the insured must contact the insurer prior to a hospitalization or surgery and receive authorization for the service.
Pre-existing Condition
A health problem that existed before the date your insurance became effective. Many insurance plans will not cover preexisting conditions. Some will cover them only after a waiting period.
Preferred Provider Organization (PPO)
A network of health care providers with which a health insurer has negotiated contracts for its insured population to receive health services at discounted costs. Health care decisions generally remain with the patient as he she selects providers and determines his or her own need for services. Patients have financial incentives to select providers within the PPO network.
Premium
The amount you or your employer pays in exchange for insurance coverage.
Primary Care Physician
Under a health maintenance organization (HMO) or point-of-service (POS) plan, usually your first contact for health care. This is often a family physician, internist, or pediatrician. A primary care physician monitors your health, treats most health problems, and refers you to specialists if necessary.
Provider
Any person (doctor or nurse) or institution (hospital, clinic, or laboratory) that provides medical care.
Third-Party Payer
Any payer of health care services other than you. This can be an insurance company, an HMO, a PPO, or the federal government.
Usual and Customary Charge
The amount a health plan will recognize for payment for a particular medical procedure. It is typically based on what is considered “reasonable” for that procedure in your service area.
Utilization Review
A cost control mechanism by which the appropriateness, necessity, and quality of health care services are monitored by both insurers and employers.
This web site is intended to be used as a tool to help teach the basics and have this material available for easy reference. The following is an introduction into life insurance:
The Basics
Why do I need Life Insurance?
Life insurance is an essential part of financial planning. One reason most people buy life insurance is to replace income that would be lost with the death of a wage earner. The cash provided by life insurance also can help ensure that your dependents are not burdened with significant debt when you die. Life insurance proceeds could mean your dependents will not have to sell assets to pay outstanding bills or taxes. An important feature of life insurance is that generally no income tax is payable on proceeds paid to beneficiaries. The death benefit of a life policy owned by a C corporation may be included in the calculation of the alternative minimum tax.
How much Insurance do I need?
Before buying life insurance, you should assemble personal financial information and review your family’s needs. There are a number of factors to consider when determining how much protection you should have. These include:
any immediate needs at the time of death, such as final illness expenses, burial costs and estate taxes;
funds for a readjustment period, to finance a move or to provide time for family members to find a job
ongoing financial needs, such as monthly bills and expenses, day-care costs, college tuition or retirement.
Although there is no substitute for a careful evaluation of the amount of coverage needed to meet your needs, one rule of thumb used is buy life insurance that is equal to five to seven times annual gross income.
If you want to be more precise, take the time and complete the Needs Analyzer
Choosing A Plan
Buying life insurance is not like any other purchase you will make. When you pay your premiums, you’re buying the future financial security of your family that only life insurance can provide. Among its many uses, life insurance helps ensure that, when you die, your dependents will have the financial resources needed to protect their home and the income needed to run a household.
Choosing a life insurance product is an important decision, but it often can be complicated. As with any other major purchase, it is important that you understand your needs and the options available to you.
The main types of life insurance available are term and permanent. Term insurance provides protection for a specified period of time. Permanent insurance provides lifelong protection. To learn more about term and permanent insurance click on the appropriate button at the top of this page..
Additional Points
1. What happens if I fail to make the required payments?
If you miss a premium payment, you typically have a 30- or 31-day grace period during which you can pay the premium. After that, the policy will lapse. You may be able to reinstate with evidence of insurability depending on your policy’s provisions. If your policy has sufficient cash value, the company can, with your authorization, draw from a permanent policy’s cash surrender value to keep that policy in force. This does not apply to term insurance because there is no cash value to draw from. In some flexible premium policies, premiums may be reduced or skipped as long as sufficient cash values remain in the policy. However, this will result in lower cash values.
2. What if I become disabled?
Provisions or riders that provide additional benefits can often be added to a policy. One such rider is a waiver of premium for disability. With this rider, if you become totally disabled for a specified period of time, you do not have to pay premiums for the duration of the disability.
3. Are other riders available?
“Accidental death benefit”, provides for an additional benefit in case of death as a result of an accident. This rider, if available, would require additional premium. Availability and specifics varies by carrier and state.
“Accelerated benefits”, also known as “living benefits.” This rider allows you, under certain circumstances, to receive the proceeds of your life insurance policy before you die. Such circumstances include terminal or catastrophic illness, the need for long-term care or confinement to a nursing home. This rider, if available, may require additional premium. Availability and specifics varies by carrier and state.
“Child rider”, provides insurance for all your children, usually from $1,000 to $20,000 of death benefit. This rider, if available, would require additional premium. Availability and specifics varies by carrier and state.
4. When will the policy be in effect?
If you decide to purchase the policy, find out when the insurance becomes effective. This could be different from the date the company issues the policy.
5. How do accelerated death benefits work?
It allows policyholders to receive all or part of the policy’s proceeds prior to death under certain circumstances, including the need for long-term care and confinement to a nursing home. Because payments may affect tax status and Medicare eligibility, and will be deducted from the overall benefits paid later to beneficiaries, policyholders should thoroughly investigate options in advance
6.By using medical tests are insurers trying to eliminate any applicant likely to develop a serious health condition?
Medical tests can provide accurate and current information about an applicant’s health, thus enabling insurers to charge premiums that reflect the level of risk an applicant represents. Because some health conditions are easily managed through proper medication, therapy or lifestyle changes, medical information sometimes makes it possible for insurers to cover applicants who might not otherwise be insurable. More serious or incurable conditions present an enormous risk that an insurer simply cannot assume.
7.What should I consider in naming life insurance beneficiaries?
Always name a “contingent,” or secondary, beneficiary, just in case you outlive your first beneficiary.
Select a specific beneficiary, rather than having the proceeds of your life insurance paid to your estate. One of the great advantages of life insurance is that it can be paid to your family immediately. If it is payable to your estate, however, it will have to go through probate with the rest of your assets.
Be very clear in wording beneficiary designations. Naming specific children may exclude those born later. If your child dies before you, do you want the proceeds to go to that child’s children? Changing the beneficiary designation is easy, but you have to remember to do it.
8. Does it make sense to replace a policy?
Think twice before you do, because in many situations it may not be to your advantage. Before dropping any in-force policy, make sure your “new” policy is paid for and in effect and first consider:
If your health status has changed over the years, you may no longer be insurable at preferred or standard rates.
Even if both policies pay “dividends,” it may be years before the new policy’s dividends equal those of your present one.
If you replace one cash-value policy with another, the cash value of the new policy may be relatively small for several years and may never be as large as that of the original one. There may also be a period wherein a surrender charge is applicable on the first policy.
You should ask for a detailed listing of cost breakdowns of both policies, including premiums, cash surrender value and death benefits. Compare these as well as the features offered by both policies.
If you decide to surrender or reduce the value of the policy you now own and replace it with other insurance, be sure your new policy is in force before you cancel the old one.
9. As a single person, do I need insurance?
The answer almost always is yes. You may want to consider these options:
Disability income insurance – especially important for self-supporting singles without sizable assets, this can replace a good part of the income you would lose if you were unable to work because of accident or illness. If you don’t have long-term disability coverage at work, it would be wise to consider an individual policy designed to replace at least 60 percent of your income.
Health insurance – if you don’t have on-the-job coverage, an individual policy is your first line of defense against ever-escalating medical and hospital costs. You can keep premium costs down by electing a large deductible, thereby “self-insuring” as much as you can afford.
Life insurance – even if you have no dependents now, you may later. If you buy now when you are younger and healthier, you can “lock in” lowest-cost coverage, including guaranteed insurability.
Please consult our Financial Representative if you have any questions – Call (855) 667-4621
The foregoing information regarding estate, charitable and/or business planning techniques is not intended to be tax, legal or investment advice and is provided for general educational purposes only. MMS Inc does not provide tax or legal advice. You should consult with your tax and legal advisor regarding your individual situation.
New York State Partnership for Long-Term Care-The Partnership was created to help New Yorkers finance long-term care without impoverishing themselves or signing over their life savings, with the accompanying loss of dignity
Employer Alliance for Affordable Health–Take action to fight unnecessary expensive health insurance mandates that increase your premiums and contribute to the number of uninsured New Yorkers.
Insurance Information Institute–The Insurance Information Institute provides facts and assistance free of charge to the media, individuals and organizations.
Individual & family – Short-term coverage available up to three years for travelers who take frequent trips throughout the year.
You have enough to worry about when you’re traveling. Don’t let your medical coverage be an uncertainty. IMGhas developed two Patriot Platinum Travel Medical Insurance plans to provide you and your family superior protection and offer a complete package of international benefits available 24 hours a day. Patriot Platinum InternationalSM provides coverage for U.S. citizens traveling outside the U.S. with coverage for brief returns to the U.S., while Patriot Platinum AmericaSM provides coverage for non-U.S. citizens traveling outside their home country. Both plans are available for a minimum of five days to a maximum of three years.Provides first-class protection for the discerning international traveler who wants to obtain the maximum coverage available in a short-term travel medical insurance product.Quote/Purchase Patriot Platinum Travel Medical InsuranceSM
Patriot Multi-Trip is designed for individuals and families who travel frequently outside their home country throughout the year. The plan offers the ease and convenience of purchasing an affordable single annual premium plan that provides coverage for trips up to 30 or 45 days in length for each trip taken during a period of 12 months. The plan provides up to $1,000,000 of medical coverage and services.There are two plans available: Patriot Multi-Trip International provides coverage for U.S. citizens that take multiple trips annually outside the U.S., and Patriot Multi-Trip America provides coverage for non-U.S. citizens that take multiple trips annually outside their home country.Quote/Purchase Patriot Multi-TripSM
Patriot T.R.I.P. Student is a budget-conscious travel insurance program designed to provide important benefits to students for many of those unforeseen circumstances that may force the cancellation or interruption of a covered trip. This program also includes coverage for trip cancellation or interruption travel and baggage delay, lost or stolen baggage, emergency medical expenses and emergency medical evacuation.
Patriot Group Travel Medical Insurance provides coverage for groups of five or more U.S. citizens and/or foreign nationals who need temporary medical insurance while traveling for business or pleasure anywhere outside their home country. It offers a 10% discount from Patriot
Travel Medical Insurance and has one easy-to-use enrollment form.
There are two Patriot Group Travel plans plans that provide up to $2,000,000 of medical coverage with a choice of deductibles and policy maximums. Patriot International Group provides coverage for U.S. citizens traveling outside the U.S. and Patriot America Group provides coverage for non-U.S. citizens traveling outside their home country. In addition to medical benefits, the plans include coverage for medical evacuation and repatriation.
Coverage can be obtained from a minimum of five days up to a maximum of two years.
“Travel Insurance” is a popular term often used to characterize a product that offers medical insurance benefits and some form of emergency assistance to cover travelers for short periods of time. Usually the time period coincides with the beginning and end of a vacation or business trip outside of the traveler’s country of residence and may extend from as short of a period as 15 days to as long as 2 years. Travel insurance is designed to allow travelers to obtain adequate health care and certain other travel related benefits while abroad which typically are not covered by their domestic insurance plan. It further protects individuals from unexpected financial liability as a result of a medical emergency and medical evacuations.
“Travel Insurance”, although used in broad terms to describe international insurance in general is only one segment of the International Insurance and Benefit Products marketplace. International Major Medical Health, Travel Medical, Travel Assistance, and International Term Life products are just some of the products designed specifically for those who are either traveling internationally, or for U.S. Citizens living abroad, or Foreign Nationals living anywhere.
The complexion of our world is changing, international travel is reaching all time levels, retirees and business people are living and working as expatriates in ever increasing numbers and many of the public medical systems in the world cannot respond to the needs of their constituents in a timely manner.
Whether you travel for business or pleasure, international travel involves risk. You may arrive at your destination to find that your luggage with personal items has disappeared. A personal emergency may necessitate your early return to your Home Country. But what would happen if you or one of your family members became ill or injured while away from home? A medical emergency may require hospitalization or even air evacuation. In most cases, your existing insurance will not provide adequate protection for these and other risks.
You have enough things to worry about when you’re traveling or living abroad. Don’t let your medical coverage and exposure to significant financial liability be one of them.
What types of plans are available?
International Travelers Coverage
Whether you are traveling internationally for business or pleasure you need medical insurance that responds to your special needs. A medical emergency may require an evacuation, a sudden illness might necessitate immediate attention by a qualified doctor, or your luggage with personal items may be lost.
The Atlas Series of coverage is designed for the individual who is traveling or residing outside of their Home Country for a period of less than one year. If you are traveling outside of your Home Country and are at lease 14 days old, you are eligible for coverage. The minimum coverage period is 15 days and the maximum coverage period is 12 months. You may purchase coverage in combinations of monthly and 15-day increments, depending on your needs.
International Major Medical Insurance
This product provides annually renewable major medical coverage for individuals and families. Coverage is available for U.S. Citizens overseas and non-U.S. Citizens anywhere, including the U.S. Whether you have relocated outside of your country of citizenship, are on an overseas assignment, or doing career mission work you need this comprehensive, portable and seamless coverage.
The International Citizen Series of coverage is available to citizens of all countries of the world who are at least 14 days, and not older than age 74. If you are a U.S. Citizen, you must reside outside the U.S., or plan to depart the U.S. within 30 days of the effective date. If you are a U.S. Citizen, you must also reside outside the U.S. for at least 6 months within each certificate period. Citizens of other countries may reside anywhere, including their country of citizenship.
Travel Accident
These products are changing dramatically from the early Accidental Death Polices that travelers purchased at airports before boarding an airplane to cover themselves should there be an air disaster. The newest policy will now provide Accidental Death and Dismemberment and Permanent and Total Disability Insurance for travelers regardless of the cause of the accident – including coverage for loses resulting from most acts of War and Terrorism.
The MultiNational Travel Accident Plan is a comprehensive Personal Accident and Assistance plan for international travelers. If you are traveling outside of your home country and are at least 18 years old but not yet 65, you are eligible for coverage. The minimum coverage period is 1 month and the maximum coverage period is 1, 3 or 12 months, depending on your destination. The plan may be purchased alone or as a supplement to other programs.
MultiNational Group Benefit Plans
Whether you are a U.S. based organization with employees overseas, or a non-U.S. organization employing expatriates, third country nationals or key local nationals, a dependable and cost effective international group benefit program is a necessity. Group rates, monthly payment options and life insurance all combine with the highest quality medical insurance to deliver reliable, responsive and cost effective coverage for small and large groups alike. As international employers seek to compete in Global markets, the challenge of attracting and retaining qualified international employees can only be met with a comprehensive international group benefit program.
A+MultiNational Group Benefit Plan is available to U.S. based organizations with a subsidiary or a division operating outside the U.S., with 3 or more international employees and is available to organizations based outside the U.S. with 3 or more employees. All active, full-time(30 hours per week or more) employees are eligible as well as dependents.
International Term Life Insurance
Obtaining quality life insurance protection while traveling or living abroad can be difficult. Our ten year level term plan can be a great supplement to your insurance portfolio.
IC+International Term Life Insurance plans are only available to individuals residing outside of the U.S. at time of application, certain other country restrictions limit the jurisdictions where the product can be written.
Travel Assistance Services
When you travel abroad or reside far from home, it’s nice to know that you are not alone. Travel Assistance Services programs are designed to help out in those situations when you need assistance and you don’t know where to turn and time is limited. Travel Assistance Services are not insurance benefits and are not a guarantee of any other benefit under the Atlas or International Citizen plans.
The following Travel Assistance Services are available 24 hours a day, 7 days a week while an Atlas, International Citizen, or Travel Accident plan is in effect.
Pre-Trip Health and Safety Advisories
(Available after purchase of coverage and before departure) – call for current passport, visa, inoculation and vaccine requirements, as well as up-to-date travel safety advisories.
Livetravel Services
– we will make emergency travel and itinerary changes for you including rebooking flights, hotel reservations and ground transportation arrangements.
BagTrak
– the industry leaders in tracking lost, checked baggage will help you locate your lost baggage, and deliver it to you anywhere in the world.
Emergency Message Relay
– will relay messages to your family, friends and co-workers, helping you to maintain contact during an emergency.
Emergency Cash Transfer
– will assist you in arranging and obtaining cash transfers anywhere in the world.
Other important Atlas/International Citizen/Travel Accident Travel Assistance Services include:
Medical referrals
Up-to-the-minute travel medical advisories
Assistance with prescription drug replacement
Dispatch of a doctor or specialist
Emergency travel arrangements for family members
Lost passport or travel documents assistance
Embassy and consulate referrals
Legal and accounting referrals
Bail bond assistance
Translation and interpretation assistance
Which plan should I purchase?
Atlas series:
Atlas International – If you are a U.S. Citizen traveling abroad for 6 months or less.
Atlas America – If you are a Non-U.S. Citizen traveling outside your Home country for 6 months or less.
Atlas Extra – Regardless of citizenship if you are planning on traveling for 6 months or more.
Atlas Professional – If you are an international traveler who requires coverage for multiple trips abroad during the year. Covered for multiple trips with durations of 30 days or less throughout the year.
International Citizens Series:
Platinum – International Citizens needing worldwide coverage.
Premier – International Citizens needing coverage outside the U.S. or Canada.
Risk Share – International Citizens who can share some risk and require coverage outside the U.S. or Canada.
MultiNational Accident Plan Series:
Travel Accident – Any International Traveler who wants to supplement their medical package with the added benefits of accidental death and disability coverage. Travelers who do not require separate medical may want to take advantage of the AD&D coverage which includes the Travel Assistance Services.
A+MultiNational Group Series:
Group Benefit Plan – Various plan designs are available for any organization outside the U.S. with 3 or more employees. Plans may include health, life dental and disability benefits.
IC+Term Life Insurance Series:
Term Life Insurance – Various life plan options are available for International Citizens residing outside the U.S. A Basic Plan, a Terminal Illness Plan, and a Double Indemnity Plan are available for term periods of up to ten years.
Doesn’t my domestic insurance plan or
medicare cover me for travel?
Perhaps. Still, there are practical considerations to take into account, which you may not be aware. The typical domestic policy has time and coverage area restrictions. Exceeding these limits can place you at risk. Medical examination notes are often written in a language other than English, and will either be the responsibility of the insured to have legally translated, or will be at best, very difficult for the domestic insurer to administer. These problems are eliminated with an experienced international claim administrator. The additional benefits listed below offer significant protection from exposures not typically accounted for in domestic coverages:
Inpatient/Outpatient/Intensive Care
Emergency Evacuation
Emergency Reunion
Repatriation of Remains
Emergency Dental
Local Ambulance
Trip Interruption
Lost Checked Luggage
Accidental Death & Dismemberment
Common Carrier Accidental Death
All of these benefits and considerations add up to a powerful case as to why you need to take the appropriate steps to insure your needs, and to protect you and your family while traveling.
It is important to review your domestic insurance policy to determine if you have coverage, limited coverage, or any coverage at all while traveling outside your home country. If you are a U.S. Resident and on medicare you should be aware that there is no medicare benefit available to you while outside the United States. For citizens of countries with a national medical program make sure that you know the plans limitations.
What is covered?
It is extremely important to be aware that different international policies have different benefit levels. Travel policies typically offer a few added features that Major Medical policies don’t have due to the special needs of the traveler in unfamiliar surroundings. Medical benefits have been modeled after traditional plans marketed in the U.S. for many years. These features are simple and easy to understand where Benefits are subject to affordable Deductibles and modest Coinsurance payments. Policy Limits will apply to all benefits in all plans.
In general terms you will find coverage options available for:
Medical – See individual plan for Schedule of Benefits and Limits
Emergency Dental – See individual plan for coverage and limitations
Emergency Evacuation – Emergency air and/or ground transportation to the nearest Hospital that is qualified to provide the medically necessary treatment.
Emergency Reunion – In the event of an emergency evacuation, the cost for transportation and lodging for up to 10 days for a relative to join you at the site where you are hospitalized.
Trip Interruption – The company will pay for your return to your Principal Residence due to the Death of an immediate family member or the destruction of your home or if after a covered emergency evacuation it is medically necessary for you to return home.
Repatriation of Remains – In the event of a covered Injury or Illness resulting in your death, your bodily remains will be prepared and transported back to your Principal Residence.
Lost Checked Luggage – In the event your checked luggage is permanently lost by the carrier you will be paid up to $250.00 for replacement of clothes and personal items.
Accidental Death and Dismemberment – See individual plan for coverage and limitations.
Common Carrier Accidental Death – See individual plan for coverage and limitations.
Return of Minor child – If minor children are traveling with a single adult who is hospitalized for a covered illness and the minor children will be left unattended for an expected time of 36 hours or more, then transportation will be arranged to return the children to their Principal Residence.
Travel Assistance Services – See individual plan for level of coverage and limitations.
What is not covered?
It is equally important to know what is not covered under international policies. Refer to the Exclusions section of the plan you are considering to see what charges, treatments, surgeries, medications, conditions and circumstances are not covered. Travel Insurance and Major medical plans treat the following items differently. Pre-existing medical conditions are not covered in general, but may be eligible for a very limited benefit in case of an acute onset. Participating in hazardous sports may be covered with the purchase of the Hazardous Sports Rider. Home Country coverage is available on a limited basis with the purchase of the Home Country Coverage Rider.
How can I obtain this coverage?
It’s easy. You may request a quote and apply on line or you may contact your agent and request a brochure and application. Atlas Travel Insurance plans can be purchased with a credit card online and policies issued and printed immediately on your computer 24 hours a day. The International Citizen Major Medical and IC+Term Life Insurance plans can be quoted and applied for on line or by mail, however approval is subject to underwriting guidelines and may require medical exams or other documentation. You may request a quote on line or by mail for the A+MultiNational Group Benefit Plan, application is by mail.
All individual product brochures include rates and an application for your convenience. If you have questions please give us a call.
Who Administers and Insures this plan?
The information contained in this section is a general representation of the products offered and concepts to be considered when traveling or residing internationally. The specific series of policies that have been mentioned or described in general: Atlas Series, International Citizen Series, Multinational Travel Accident, A+MultiNational Group Series, and IC+Term Life Insurance Series, are policies issued and insured by the Administrator and Insurer listed below. Please refer to the actual policy details from the carrier for an accurate and legal description of these plans.
MultiNational Underwriters, Inc, headquartered in Indianapolis, Indiana, is a full service organization offering a comprehensive portfolio of insurance products designed specifically to address the insurance needs of international travelers. A Travel Guard® International company, that benefits from the experience of a corporate group that protected over 6 million travelers last year. International claims specialist, medical professionals, and customer service representatives are available 24 hours a day, 7 days a week to answer your questions and respond to your needs. Whether you have lost your luggage or are in need of Emergency Evacuation, you will find a service team which is prompt, compassionate and of the highest professional quality ready to assist you.
Lloyd’s the largest and oldest insurance market in the world, is the insurer of these unique insurance products. Rated A-by AM Best Company and A by Standard and Poor’s, Lloyd’s provides financial strength and security that is unparalleled in the worldwide insurance market. Lloyd’s is recognized as a market leader in the accident and health insurance arena, and is well-known for its innovative products and services. Presently, Lloyd’s provides accident and health insurance to millions of individuals in almost every country in the world.
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You can choose different ways to get the services covered by Medicare. Depending on where you live, you may have different choices. In most cases, when you first get Medicare, you are in the Original Medicare Plan. Or, you may want to consider a Medicare Advantage Plan (like an HMO or PPO) that provides all your Part A, Part B, and often Part D (Medicare Prescription Drug) coverage. You make a choice when you are first eligible for Medicare. Each year you can review your health and prescription needs and switch to a different plan in the fall.
Medicare Advantage Plans are health plan options that are approved by Medicare but run by private companies. They are part of the Medicare Program, and sometimes called “Part C.” When you join a Medicare Advantage Plan, you are still in Medicare. As long as you have both Part A and Part B, items covered by Part A and Part B are covered whether you have the Original Medicare Plan, or you belong to a Medicare Advantage Plan (like an HMO or PPO).
Medicare Prescription Drug Plans are offered by insurance companies and other private companies approved by Medicare.
Medicare Health Plans
Today’s Medicare is about choice. Your health plan choices include:
The Original Medicare Plan
Medicare + Choice Plans, including:
Medicare Managed Care Plans
Medicare Private Fee-for-Service Plans
Medicare Preferred Provider Organization Plans
Medicare + Choice Plans are available in many areas.
The Medicare health plan that you choose affects many things like cost, benefits (some have extra benefits like prescription drugs), doctor choice, convenience, and quality.
Medicare Part A (Hospital Insurance) helps cover your inpatient care in hospitals, including critical access hospitals, and skilled nursing facilities (not custodial or long-term care). It also helps cover hospice care and some home health care. You must meet certain conditions.
Cost
Most people do not pay a monthly Part A premium because they paid Medicare taxes while working.
In 2011, you pay up to $450 each month if you don’t get premium free Part A. If you pay a late enrollment penalty, this amount is higher.
Medicare Part A Helps Cover Your Medically Necessary:
Hospital Stays
Semiprivate room, meals, general nursing, and other hospital services and supplies. This includes inpatient care you get in critical access hospitals and mental health care. This doesn’t include private duty nursing, or a television or telephone in your room. It also doesn’t include a private room, unless medically necessary. Inpatient mental health care in a psychiatric facility is limited to 190 days in a lifetime.
Skilled Nursing Facility Care
Semiprivate room, meals, skilled nursing and rehabilitative services, and other services and supplies (after a related 3-day inpatient hospital stay).
Home Health Care
Part-time or intermittent skilled nursing care and home health aide services, physical therapy, occupational therapy, speech-language therapy, medical social services, durable medical equipment (such as wheelchairs, hospital beds, oxygen, and walkers), medical supplies, and other services.
Hospice Care
For people with a terminal illness, includes drugs for symptom control and pain relief, medical and support services from a Medicare-approved hospice, and other services not otherwise covered by Medicare. Hospice care is usually given in your home. However, Medicare covers some short-term hospital and inpatient respite care (care given to a hospice patient so that the usual caregiver can rest).
Blood
Pints of blood you get at a hospital or skilled nursing facility during a covered stay.
Medicare Part B (Medical Insurance) helps cover your doctors’ services and outpatient hospital care. It also covers some other medical services that Part A doesn’t cover, such as some of the services of physical and occupational therapists, and some home health care. Part B helps pay for these covered services and supplies when they are medically necessary.
Cost
Most people will continue to pay the same premium they paid last year. The 2011 Medicare Premium for Part B is $115.40 per month. In some cases, this amount may be higher if you didn’t sign up for Part B when you first became eligible. The cost of Part B may go up 10% for each 12-month period that you could have had Part B but didn’t sign up for it, except in special cases. You will have to pay this extra amount as long as you have Part B.
Medicare Part B Helps Cover Your Medically Necessary:
Medical and Other Services
Doctors’ services (not routine physical exams), outpatient medical and surgical services and supplies, diagnostic tests, ambulatory surgery center facility fees for approved procedures, and durable medical equipment (such as wheelchairs, hospital beds, oxygen, and walkers). Also covers second surgical opinions, outpatient mental health care, and outpatient occupational and physical therapy including speech-language therapy. (These services are also covered for long-term nursing home residents.).
Clinical Laboratory Services
Blood tests, urinalysis, some screening tests, and more.
Home Health Care
Part-time or intermittent skilled nursing care and home health aide services, physical therapy, occupational therapy, speech-language therapy, medical social services, durable medical equipment (such as wheelchairs, hospital beds, oxygen, and walkers), medical supplies, and other services.
Outpatient Hospital Services
Hospital services and supplies received as an outpatient as part of a doctor’s care.
Blood
Pints of blood you get as an outpatient or as part of a Part B covered service.
What is the Original Medicare Plan?
The Original Medicare Plan is a “fee-for-service” plan. This means you are usually charged a fee for each health care service or supply you get. This plan, managed by the Federal Government, is available nationwide. If you are in the Original Medicare Plan, you use your red, white, and blue Medicare card when you get health care. If you are happy getting your health care this way, you don’t have to change. You will stay in the Original Medicare Plan unless you choose to join a Medicare + Choice Plan.
Whether your doctor or supplier agrees to accept “assignment”
How often you need health care
What type of health care you need
Whether you choose to get services or supplies not covered by Medicare. In this case, you would pay for these services yourself.
Whether you have other insurance
Turning 65? Retiring? For more information on COBRA and Medicare or to schedule a call please contact us at 855-667-4621 or info@medicalsolutionscorp.com.
Today, health care costs are high, and getting higher. Who will pay your bills if you have a serious accident or a major illness? You buy health insurance for the same reason you buy other kinds of insurance, to protect yourself financially. With health insurance, you protect yourself and your family in case you need medical care that could be very expensive. You can’t predict what your medical bills will be. In a good year, your costs may be low. But if you become ill, your bills could be very high. If you have insurance, many of your costs are covered by a third-party payer, not by you. A third-party payer can be an insurance company or, in some cases, it can be your employer.
Evolution
Health care in America is changing rapidly. Twenty-five years ago, most people in the United States had indemnity insurance coverage. A person with indemnity insurance could go to any doctor, hospital, or other provider (which would bill for each service given), and the insurance and the patient would each pay part of the bill.
But today, more than half of all Americans who have health insurance are enrolled in some kind of managed care plan, an organized way of both providing services and paying for them. Different types of managed care plans work differently and include preferred provider organizations (PPOs), health maintenance organizations (HMOs), and point-of-service (POS) plans.
You’ve probably heard these terms before. But what do they mean, and what are the differences between them? And what do these differences mean to you?
Types of Insurance
Fee-for-Service (Indemnity Plan)This is the traditional kind of health care policy. Insurance companies pay fees for the services provided to the insured people covered by the policy. This type of health insurance offers the most choices of doctors and hospitals. You can choose any doctor you wish and change doctors any time. You can go to any hospital in any part of the country.
With fee-for-service, the insurer only pays for part of your doctor and hospital bills. This is what you pay:
A monthly fee, called a premium.
A certain amount of money each year, known as the deductible, before the insurance payments begin. In a typical plan, the deductible might be $250 for each person in your family, with a family deductible of $500 when at least two people in the family have reached the individual deductible. The deductible requirement applies each year of the policy. Also, not all health expenses you have count toward your deductible. Only those covered by the policy do. You need to check the insurance policy to find out which ones are covered.
After you have paid your deductible amount for the year, you share the bill with the insurance company. For example, you might pay 20 percent while the insurer pays 80 percent. Your portion is called coinsurance.
To receive payment for fee-for-service claims, you may have to fill out forms and send them to your insurer. Sometimes your doctor’s office will do this for you. You also need to keep receipts for drugs and other medical costs. You are responsible for keeping track of your medical expenses.
There are limits as to how much an insurance company will pay for your claim if both you and your spouse file for it under two different group insurance plans. A coordination of benefit clause usually limits benefits under two plans to no more than 100 percent of the claim.
Most fee-for-service plans have a “cap,” the most you will have to pay for medical bills in any one year. You reach the cap when your out-of-pocket expenses (for your deductible and your coinsurance) total a certain amount. It may be as low as $1,000 or as high as $5,000. Then the insurance company pays the full amount in excess of the cap for the items your policy says it will cover. The cap does not include what you pay for your monthly premium.
Some services are limited or not covered at all. You need to check on preventive health care coverage such as immunizations and well-child care.
There are two kinds of fee-for-service coverage: basic and major medical. Basic protection pays toward the costs of a hospital room and care while you are in the hospital. It covers some hospital services and supplies, such as x-rays and prescribed medicine. Basic coverage also pays toward the cost of surgery, whether it is performed in or out of the hospital, and for some doctor visits. Major medical insurance takes over where your basic coverage leaves off. It covers the cost of long, high-cost illnesses or injuries.
Some policies combine basic and major medical coverage into one plan. This is sometimes called a “comprehensive plan.” Check your policy to make sure you have both kinds of protection.
What Is a “Customary” Fee?Most insurance plans will pay only what they call a reasonable and customary fee for a particular service. If your doctor charges $1,000 for a hernia repair while most doctors in your area charge only $600, you will be billed for the $400 difference. This is in addition to the deductible and coinsurance you would be expected to pay. To avoid this additional cost, ask your doctor to accept your insurance company’s payment as full payment. Or shop around to find a doctor who will. Otherwise you will have to pay the rest yourself.
Questions to Ask About Fee-for-Service (Indemnity) Insurance
How much is the monthly premium? What will your total cost be each year? There are individual rates and family rates.
What does the policy cover? Does it cover prescription drugs, out-of-hospital care, or home care? Are there limits on the amount or the number of days the company will pay for these services? The best plans cover a broad range of services.
Are you currently being treated for a medical condition that may not be covered under your new plan? Are there limitations or a waiting period involved in the coverage?
What is the deductible? Often, you can lower your monthly health insurance premium by buying a policy with a higher yearly deductible amount.
What is the coinsurance rate? What percent of your bills for allowable services will you have to pay?
What is the maximum you would pay out of pocket per year? How much would it cost you directly before the insurance company would pay everything else?
Is there a lifetime maximum cap the insurer will pay? The cap is an amount after which the insurance company won’t pay anymore. This is important to know if you or someone in your family has an illness that requires expensive treatments.
Health Maintenance Organizations (HMOs)Health maintenance organizations are prepaid health plans. As an HMO member, you pay a monthly premium. In exchange, the HMO provides comprehensive care for you and your family, including doctors’ visits, hospital stays, emergency care, surgery, lab tests, x-rays, and therapy.
The HMO arranges for this care either directly in its own group practice and/or through doctors and other health care professionals under contract. Usually, your choices of doctors and hospitals are limited to those that have agreements with the HMO to provide care. However, exceptions are made in emergencies or when medically necessary.
There may be a small co-payment for each office visit, such as $5 for a doctor’s visit or $25 for hospital emergency room treatment. Your total medical costs will likely be lower and more predictable in an HMO than with fee-for-service insurance.
Because HMOs receive a fixed fee for your covered medical care, it is in their interest to make sure you get basic health care for problems before they become serious. HMOs typically provide preventive care, such as office visits, immunizations, well-baby checkups, mammograms, and physicals. The range of services covered vary in HMOs, so it is important to compare available plans. Some services, such as outpatient mental health care, often are provided only on a limited basis.
Many people like HMOs because they do not require claim forms for office visits or hospital stays. Instead, members present a card, like a credit card, at the doctor’s office or hospital. However, in an HMO you may have to wait longer for an appointment than you would with a fee-for-service plan.
In some HMOs, doctors are salaried and they all have offices in an HMO building at one or more locations in your community as part of a prepaid group practice. In others, independent groups of doctors contract with the HMO to take care of patients. These are called individual practice associations (IPAs) and they are made up of private physicians in private offices who agree to care for HMO members. You select a doctor from a list of participating physicians that make up the IPA network. If you are thinking of switching into an IPA-type of HMO, ask your doctor if he or she participates in the plan.
In almost all HMOs, you either are assigned or you choose one doctor to serve as your primary care doctor. This doctor monitors your health and provides most of your medical care, referring you to specialists and other health care professionals as needed. You usually cannot see a specialist without a referral from your primary care doctor who is expected to manage the care you receive. This is one way that HMOs can limit your choice.
Before choosing an HMO, it is a good idea to talk to people you know who are enrolled in it. Ask them how they like the services and care given.
Questions to Ask About an HMO
Are there many doctors to choose from? Do you select from a list of contract physicians or from the available staff of a group practice? Which doctors are accepting new patients? How hard is it to change doctors if you decide you want someone else? How are referrals to specialists handled?
Is it easy to get appointments? How far in advance must routine visits be scheduled? What arrangements does the HMO have for handling emergency care?
Does the HMO offer the services I want? What preventive services are provided? Are there limits on medical tests, surgery, mental health care, home care, or other support offered? What if you need a special service not provided by the HMO?
What is the service area of the HMO? Where are the facilities located in your community that serve HMO members? How convenient to your home and workplace are the doctors, hospitals, and emergency care centers that make up the HMO network? What happens if you or a family member are out of town and need medical treatment?
What will the HMO plan cost? What is the yearly total for monthly fees? In addition, are there copayments for office visits, emergency care, prescribed drugs, or other services? How much?
Preferred Provider Organizations (PPOs)The preferred provider organization is a combination of traditional fee-for-service and an HMO. Like an HMO, there are a limited number of doctors and hospitals to choose from. When you use those providers (sometimes called “preferred” providers, other times called “network” providers), most of your medical bills are covered.
When you go to doctors in the PPO, you present a card and do not have to fill out forms. Usually there is a small copayment for each visit. For some services, you may have to pay a deductible and coinsurance.
As with an HMO, a PPO requires that you choose a primary care doctor to monitor your health care. Most PPOs cover preventive care. This usually includes visits to the doctor, well-baby care, immunizations, and mammograms.
In a PPO, you can use doctors who are not part of the plan and still receive some coverage. At these times, you will pay a larger portion of the bill yourself (and also fill out the claims forms). Some people like this option because even if their doctor is not a part of the network, it means they don’t have to change doctors to join a PPO.
Questions to Ask About a PPO
Are there many doctors to choose from? Who are the doctors in the PPO network? Where are they located? Which ones are accepting new patients? How are referrals to specialists handled?
What hospitals are available through the PPO? Where is the nearest hospital in the PPO network? What arrangements does the PPO have for handling emergency care?
What services are covered? What preventive services are offered? Are there limits on medical tests, out-of-hospital care, mental health care, prescription drugs, or other services that are important to you?
What will the PPO plan cost? How much is the premium? Is there a per-visit cost for seeing PPO doctors or other types of co-payments for services? What is the difference in cost between using doctors in the PPO network and those outside it? What is the deductible and coinsurance rate for care outside of the PPO? Is there a limit to the maximum you would pay out of pocket?
Point-of-Service (POS) PlanMany HMOs offer plan members the option to self direct care, as one would under an indemnity or PPO plan, rather than get referrals from primary care physicians. An HMO with this opt-out provision is known as a point-of-service (POS) plan. How the plan functions (i.e., like an HMO or like an indemnity plan) depends on whether individual plan members use their primary care physician or self direct their care at the “point of service.”
To illustrate this point, this is how these plans typically work. When medical care is needed, the individual plan member essentially has up to two or three choices, depending on the particular health plan. The plan member can choose to go through his or her primary care physician, in which case services will be covered under HMO guidelines (i.e., usually a co-payment will be required). Alternatively, the plan member can access care through a PPO provider and the services will be covered under in-network PPO rules (i.e., usually a co-payment and coinsurance will be required). Lastly, if the plan member chooses to obtain services from a provider outside of the HMO and PPO networks, the services will be reimbursed according to out-of-network rules (i.e., usually a co-payment and higher coinsurance charge will be required). Because people who belong to POS plans are responsible for deciding how to access care within the various options, it is important that they understand the financial implications of these choices.
Where Do People Get Health Insurance Coverage?
Group InsuranceMost Americans get health insurance through their jobs or are covered because a family member has insurance at work. This is called group insurance. Group insurance is generally the least expensive kind. In many cases, the employer pays part or all of the cost.
Some employers offer only one health insurance plan. Some offer a choice of plans: a fee-for-service plan, a health maintenance organization (HMO), or a preferred provider organization (PPO), for example. Employers with 25 or more workers are required by Federal law to offer employees the chance to enroll in an HMO.
What happens if you or your family member leaves the job? You will lose your employer- supported group coverage. It may be possible to keep the same policy, but you will have to pay for it yourself. This will certainly cost you more than group coverage for the same, or less, protection.
A Federal law makes it possible for most people to continue their group health coverage for a period of time. Called COBRA (for the Consolidated Omnibus Budget Reconciliation Act of 1985), the law requires that if you work for a business of 20 or more employees and leave your job or are laid off, you can continue to get health coverage for at least 18 months. You will be charged a higher premium than when you were working.
You also will be able to get insurance under COBRA if your spouse was covered but now you are widowed or divorced. If you were covered under your parents’ group plan while you were in school, you also can continue in the plan for up to 18 months under COBRA until you find a job that offers you your own health insurance.
Not all employers offer health insurance. You might find this to be the case with your job, especially if you work for a small business or work part-time. If your employer does not offer health insurance, you might be able to get group insurance through membership in a labor union, professional association, club, or other organization. Many organizations offer health insurance plans to members.
Individual InsuranceIf your employer does not offer group insurance, or if the insurance offered is very limited, you can buy an individual policy. You can get fee-for-service, HMO, or PPO protection. But you should compare your options and shop carefully because coverage and costs vary from company to company. Individual plans may not offer benefits as broad as those in group plans.
If you get a non-cancelable policy (also called a guaranteed renewable policy), then you will receive individual insurance under that policy as long as you keep paying the monthly premium. The insurance company can raise the cost, but cannot cancel your coverage. Many companies now offer a conditionally renewable policy. This means that the insurance company can cancel all policies like yours, not just yours. This protects you from being singled out. But it doesn’t protect you from losing coverage.
Before you buy any health insurance policy, make sure you know what it will pay for…and what it won’t. To find out about individual health insurance plans, you can call insurance companies, HMOs, and PPOs in your community, or speak to your insurance agent.
Tips when shopping for individual insurance:
Shop carefully. Policies differ widely in coverage and cost. Contact different insurance companies, or ask your agent to show you policies from several insurers so you can compare them.
Make sure the policy protects you from large medical costs.
Read and understand the policy. Make sure it provides the kind of coverage that’s right for you. You don’t want unpleasant surprises when you’re sick or in the hospital.
Check to see that the policy states: the date that the policy will begin paying (some have a waiting period before coverage begins), and what is covered or excluded from coverage.
Make sure there is a “free look” clause. Most companies give you at least 10 days to look over your policy after you receive it. If you decide it is not for you, you can return it and have your premium refunded.
Beware of single disease insurance policies. There are some polices that offer protection for only one disease, such as cancer. If you already have health insurance, your regular plan probably already provides all the coverage you need. Check to see what protection you have before buying any more insurance.
MedicareMedicare is the Federal health insurance program for Americans age 65 and older and for certain disabled Americans. If you are eligible for Social Security or Railroad Retirement benefits and are age 65, you and your spouse automatically qualify for Medicare.
Medicare has three parts: hospital insurance, known as Part A, supplementary medical insurance, known as Part B, which provides payments for doctors and related services and supplies ordered by the doctor, and prescription drug coverage, known as Part D which covers both brand-name and generic prescription drugs at participating pharmacies in your area. If you are eligible for Medicare, Part A is free, but you must pay a premium for Part B and Part D.
Medicare will pay for many of your health care expenses, but not all of them. In particular, Medicare does not cover most nursing home care, long-term care services in the home, or prescription drugs. There are also special rules on when Medicare pays your bills that apply if you have employer group health insurance coverage through your own job or the employment of a spouse.
Medicare usually operates on a fee-for-service basis. HMOs and similar forms of prepaid health care plans are now available to Medicare enrollees in some locations.
The best source of information on the Medicare program is the Medicare Handbook. This booklet explains how the Medicare program works and what your benefits are. To order a free copy, go to: www.medicare.gov. You also can contact your local Social Security office for information.
Some people who are covered by Medicare buy private insurance, called “Medigap” policies, to pay the medical bills that Medicare doesn’t cover. Some Medigap policies cover Medicare’s deductibles; most pay the coinsurance amount. Some also pay for health services not covered by Medicare. There are 10 standard plans from which you can choose. (Some States may have fewer than 10.) If you buy a Medigap policy, make sure you do not purchase more than one.
You need to shop carefully before deciding on the best policy to fit your needs. You may get another booklet, Guide to Health Insurance for People with Medicare, to help you in making the right choice. To order a free copy, go to:www.medicare.gov.
Another good source of information on the same topic is The Consumer’s Guide to Medicare Supplement Insurance. To order a free copy, go to: www.medicare.gov.
MedicaidMedicaid provides health care coverage for some low-income people who cannot afford it. This includes people who are eligible because they are aged, blind, or disabled or certain people in families with dependent children. Medicaid is a Federal program that is operated by the States, and each State decides who is eligible and the scope of health services offered.
General information on the Medicaid program is given in the Medicaid Fact Sheet. For a free copy, go to: www.medicare.gov. For specifics on Medicaid eligibility and the health services offered, contact your State Medicaid Program Office.
