health insurance 411
Post on 07-Sep-2014
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Your guide to all your health insurance needs
Presented By:
Cost of Health Insurance1. Dramatically Rising
New Technology / Equipment
Rx costs
Covering the Uninsured
Hospital Costs
Shift - Types of insurance & Cost Sharing by Employers
3
Styles of Health InsuranceHMO: Health Maintenance Organization
PPO: Participating Provider Organization
HDHP with HSAs: High Deductible Health
Plan that may be paired with the financial
product, a Health Saving Account.
Definitions used in Health Insurance Copays:
Deductible:
Coinsurance:
OOP (Out of Pocket Maximum):
Life Time Maximum
Dollar amount that offsets partially the cost of medical care
Dollar amount to be paid for medical services before insurance coverage engages
Percentage or cost sharing of medical expense after deductible is met.
Maximum amount to be paid by enrollee before insurance covers expenses fully
The maximum liability that the policy will cover
Definitions Continued…
Rx 15/35/50/30% Generic Brand Name Non – Formulary Self injectibles
The categories have been changing
Example of an HMO
Example of an PPO
Example of HSA Eligible
Health Savings AccountsBank Account paired with H.D.H.P
Employers and /or Employees can fund the account
Account is owned by the employee or individual who
is primary on the health insurance
Tax Deductible Contribution –
Tax Free Withdrawals – Eligible Medical Expenses
Other StylesIndemnity: Traditional format with no in or
out of network contract
Limited Benefit: Newer Major Medical that
may cover only some hospitalization, ER
visits, and limit OOP and/or lifetime
maximums
Non Insurance Discount Programs
Network Plans
Promise – Can’t Be Turned Down
Office Visit??
Rx Covered ???
What’s Left Out????
Definitions Continued…Preventative:
Diagnostic:
Annual, nationally listed care for children & adults, i.e., immunizations, mammograms, PSA
Treatment or testing for existing conditions
Definitions Continued…Behavioral Health
Mental Health, Substance Abuse, Alcohol Abuse
Limited Benefits - inpatient 45 days / yr. outpatient 20 visits/ yr. detox – 3 days
Substance Abuse – very limited benefitsParity - treat mental health at the same level
as physical health -State Reg - Biologically Based Mental Illness –
ParityReality Check
Available Health Insurance Coverage
1. Individual and Family Plans
2. Short-Term Health Insurance- 30 days to 6
months
3. Employer Sponsored Plans
4. Medicare / Medicaid/ Cover Colorado/ CHP
Individual and Family Plans
Eligibility based on health underwriting
Lower Cost - due to a healthier population
Paid by the individual
Health Issues Riders
Rate ups
Decline
Short Term Health InsuranceImmediate Coverage –PPO
Major Med for Hospital & ER
30 days to 6 months
Can be declined for pre-existing conditions
Do not cover pre-existing conditions
Good for the gap between becoming eligible
at a new job, or recent university grads
Employer Sponsored Plans Small Group Plans
Business Group of One
2-50 Employees
Large Group Plans
51 + Employees (some carriers consider
>100)
Employer Sponsored PlansBusiness Group of One (BGO)
Guaranteed Issue
State Mandated Plans
Standard & Basic HMO & PPO plans
Indemnity Plans
Open Enrollment periods
Proof of Business
Employer Sponsored PlansSmall Group 2-50 employees
Guaranteed Issue
Proof of Business Rates Based Upon Plan Design, Age, SIC Code and
Tobacco Usage
State Mandated Coverages
Basic plans – stripping out some of the preventative
Table Rates or Composite Rates
Example Rate Table
Employer Sponsored PlansLarge Group 51 + employees
Not Guaranteed Issue
Rates Based upon Health Experience, Age, and
Plan Design
SIC Code and Tobacco Usage Play a part in the
rates.
Larger Groups - rates are Negotiable
Proof of Business
Employer Sponsored Plans
Self Funded Plans share the risk with
employers Employer Pays Claims up to individual & group limits
TPA or Insurance Company Administers Claims
Stop Loss Limits - Cap Liability
Lower Initial Cost but Higher Risk
Enrollment EligibilityQualifying Events
Major Life Events, i.e., Birth, Adoption, Legal Guardianship, Marriage, Divorce, Death
Loss of coverage through no choice of your ownOpen EnrollmentNew Hires - waiting periodPre existing conditions
FraudSee Colorado Division of Insurance definitions
MIB (Medical Information Bureau)Like a credit bureau, has records of your medical history,
and can be checked annually for accuracy to control ID theft. Also IntelliScript checks for filled prescriptions.
HIPPAHealth Insurance Portability and Accountability
Act,PrivacyRight to Convert
COBRA/ State ContinuationCOBRA is federal law mandating the right to
temporarily continue group health coverage for a period of time
State Continuation is state law to fill in gaps left by COBRA for employee groups with less than 20 employees
COBRA/ State Continuation
New Federal Regulation : Federal Government will subsidize 65% of Premium for up to 9 Months.
If Business Fails - COBRA ends
New COBRA RegulationsFor involuntary loss of employment onlyLoss of employment from 9/1/08 to 12/31/09If from 9/1/08 to present you have had employees
eligible for COBRA must contact them with the new eligibility period (from 2/17/09 for 60 days forward)
Starting 3/1/09 employees that elect this coverage will pay 35% of the premium.
Starting 3/1/09 employers of these electees will pay 65% to be reimbursed on their payroll taxes.
End of COBRA or Continuation
Conversion or CoverColoradoThe right to convert a group health insurance
policy after completion of COBRA, being ineligible for individual health insurance due to significant pre-existing conditions. Premiums may be up to 2.5 times of normal
CoverColorado is our state’s “uninsurable risk pool”, providing insurance for those who are declined individual health insurance coverage or who have certain listed conditions
Web Access
Health Resources Access health and
wellness information.
Health Extras Maximize opportunities
for better health.
Health Guidance Get help when in need of
care.
Health Management Receive ongoing
management and help coordinating your care.
We’ve designed a broad spectrum of health services to meet the needs of your total member population.
Anthem Blue Cross 360º Health Services Overview
MyHealth@AnthemMembers will have their own, personalized health resource center on the web. Healthy Living offers interactive tools to help your employees assess, manage and improve their health.
Sections include: Children’s Health News Men’s Health Women’s Health Mental Health Alternative Medicine Daily Health Tips
Healthy Living provides timely, trusted and personalized information to engage members
Anthem Blue Cross360º Health Resources
Web AccessEmployers
Real time access for HR to manage enrollments and terminations of employees, and billing
MedicarePart A- Hospitalization: entitled to premium-free
enrollment if you or your spouse paid Medicare
taxes
Part B- Doctor and lab coverage: Income based
premium from SS check or self paid
Part D- Rx coverage
Medicare Continued…Medicare Advantage Medicare SupplementsSometimes referred to
as Medicare Part C, a hybrid of Part A, B, and D that are assigned to the carriers
Uses contracted doctors and hospitals only
Useful outside of contract area only in emergencies
Kaiser, Secure Horizons
Also called Medigap plans, originally had 10 plan levels
Need to purchase Medicare Part D coverage for RX needs
Has in and out of network benefits, so it travels better for “snowbirds”
AARP - United
Medicare Continued…Group Size determines whether Medicare is
Primary or Secondary in paying claimsSecondary coverage acts as Medicare “supplement”Medicare Eligible cannot contribute to funding
HSAsSome disabilities before age 65 are Medicare
eligibleCarriers must annually report enrolled Medicare
persons on group plans to be in compliance with new law. Employer groups will need to share SS# of people that are Medicare eligible.
Colorado Division of InsuranceConsumer Protection is their mission
Source of consumer information
Performs market conduct and financial exams on
insurance companies
File consumer complaints online or call 303-894-
7490
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