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.
Sign up for latest news updates. Please contact us for immediate information on how to implement these initiatives for your group-specific needs at info@medicalsolutionscorp.com or Call (855) 667-4621.
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.
Your costs in the Original Medicare Plan
What you pay out-of-pocket depends on:
Whether you have Part A and Part B
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.
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.
Most, if not all, of the insurance companies in the market include as one of their plans the combination of a health savings account and a high–deductible plan. EmblemHealth, for instance, offers a plan for $170 a month. These plans are very bare bones. The EmblemHealth plan has a deductible of $5,000. That’s not anyone’s idea of a rich benefit plan. When coupled with a health savings account, which gives the business and the employee the chance to make tax–free contributions toward expenses below that deductible, such plans do help employees with routine expenses and cover workers in case of a catastrophic illness.
Why do my rates keep going up?
Some plans raise rates sharply in the first few years of a plan because expenses were higher than actuaries predicted. But the big reason that costs for health care keep rising for small and large businesses is that people are using more health care services.
What will happen if I have a catastrophic claim?
Nothing. New York law prevents insurers from raising your rates based on your claims history.
How can I make sure the plan I choose has a good network?
You have to look at the fine print and decide what you want. There’s no guarantee that the doctor, or even the hospital you want, will be in–network. Memorial Sloan–Kettering Cancer Center, for instance, is not included in the networks of some low–cost plans.
How much will health care cost?
Most businesses we talk to that offer health insurance offer plans in the range of $350 to $450 a month and pay a part of the premium for employees.
Do I have to buy dental and vision insurance from the same company that I buy my major medical plan from?
No. In fact, it pays to shop around.
Are rates going to keep increasing?
There’s no real end in sight, unless health reform in Washington radically changes the market. Annual increases in the small business market have been in the mid– to high double–digits for several years.
What are my competitors in the labor market offering?
According to the National Federal of Independent Business, about 60% of small businesses offer health insurance to their employees and typically pay a greater share of expenses than big businesses.
What is an Explanation of Benefits (EOB)?
An Explanation of Benefits (EOB) is the form that is sent to the patient from the carrier to explain the charges that have been assigned to the carrier and the amount that the carrier has indicated that they will pay for the services rendered.
I have received an Explanation of Benefits (EOB) from the Carrier, what do I need to do?
The employee should contact the insurance carrier first to verify if the bill has been submitted to the carrier and processed.
I have received a bill from the provider but the services should be covered by my insurance plan, what should I do?
The employee should contact the insurance carrier first to verify if the bill has been submitted to the carrier and processed.
If it has been received and processed, the employee will need to ask how the claim was processed to be sure that it was paid correctly.
If the claim has been received but not yet processed, the employee should ask the carrier if any additional information is needed to process the claim.
If the claim is not on file, the employee should contact the provider and request that they resubmit the claim to the carrier for processing.
What do I do if I have just enrolled in my insurance plan and have not yet received my ID card but need to see a doctor or get a prescription?
Contact a KYBA Benefits Account Manager who will contact the carrier and check the status of the application and see if ID cards have been mailed.
If the employee is listed in the system, the employee should schedule an appointment with the provider and provide them with a Social Security number and Group number so the provider can call and verify benefits in order to treat the employee and/or fill a prescription.
If the employee is not listed in the system, the employee can still see a provider by giving the provider the Social Security number and Group number, however, the employee should request that the provider not file the claim until the application is in the carrier system. If a prescription is needed prior to being in the system, the employee will need to pay for the medication and submit a claim form in order to get reimbursement up to the copay amount. In the mean time, the KYBA Benefits Account Manager will be working to get the application expedited in to the carrier’s system.
What should I do if my address has changed?
The employee should contact the HR Administrator at their employer to notify them of the change AND contact the customer service department of the insurance carrier to notify them of the address change.
How do I add or delete a dependent from my plan?
If there is a qualifying event or if the necessary change is during open enrollment, the employee will need to complete a change form for each carrier that is affected by the change and submit the form to the appropriate carriers.
What is Initial Enrollment for a New Employee?
Initial Enrollment is the first opportunity when you and your eligible dependents can enroll in your benefits. There are certain advantages of enrolling in benefits during your Initial Enrollment that are never offered again.
Examples of this include but are not limited to:
Dental Insurance plans have Late Entrant Penalties. If you add Dental Insurance to your coverage after your Initial Offering you will have to wait for certain benefits to take effect. Please review your Benefits Kit for the specific Late Entrant Penalties timetables.
Supplemental Life Insurance plans offer guarantee issue limits offered during your Initial Offering. You are able to enroll up to these limits without evidence of insurability. If you do not take advantage of this initial offering, your next opportunity would require you and your dependents to provide evidence of insurability where you and your dependents may be declined coverage.
Supplemental Disability Insurance plans offer guarantee issue limits offered only during your Initial Offering. You are able to enroll up to these limits without evidence of insurability. If you do not take advantage of this Initial Offering, your next opportunity would require you to provide evidence of insurability where you may be declined coverage.
How do I enroll as a New Employee?
Carefully review all the information in your Benefits Packet before making any decisions.
Make your benefit elections by completing the enrollment form(s) provided by your HR Administrator.
Return your completed enrollment form(s) to Human Resources right away but no later than the effective date of your benefits.
By waiting until your effective date to submit enrollment form(s) you may experience several problems, which include but are not limited to:
Inability to access benefits on your effective date
Delay in receiving your ID Card for up to 3 weeks from the date you submit your form(s) will create several problems.
Not have ID cards on your effective date
When is the next opportunity to enroll or make changes in my benefits?
The next time you can make changes or enroll is the next Open Enrollment or Qualifying Event. Outside of Open Enrollment, the only time you or your eligible dependents can make a change in your benefits is during a Qualifying Event.
What is a Qualifying Event?
A Qualifying Event is a significant change in a person’s life that creates the need to add, drop, increase or change coverage. Outside of Open Enrollment, the only other time you can enroll, change or delete your benefit options is within 30 days of a Qualifying Event.
Examples of qualifying events include, but are not limited to, the following:
Marriage or Divorce of the employee
Death of the employee’s spouse or dependent
Birth or Adoption of a Child
Start or End of employment of the employee’s spouse
Change in status or employment of the employee or spouse
Significant change in health coverage of the employee or spouse due to the spouse’s employment
ONCE AGAIN…You MUST submit your request to change within 30 days of the Qualifying Event or it will be DECLINED!
What is Open Enrollment?
Open Enrollment is the annual event, for certain benefits, where you and your eligible dependents can request changes in your election and apply for coverage.
When can I drop benefits?
Benefits can be dropped ONLY during the Open Enrollment period OR if a Qualifying Event occurs.
The Personal Health Advocate is a trained professional, typically a Registered Nurse, who understands the intricacies of the healthcare system and how to navigate through it. As soon as a member contacts us he/she establishes a relationship with a Personal Health Advocate who stays with them through to the resolution of the problem. Our Personal Health Advocates demonstrate a commitment to service excellence, have strong problem solving skills and support members as they seek healthcare services and interact with providers and insurers. Personal Health Advocates work in tandem with Medical Directors and with our team of administrative experts who handle claims, benefits, grievances and paperwork issues.
Health Advocate is available 24 hours a day, 7 days a week using a toll free phone number. Regular hours extend from 8 AM to 6 PM weekdays. After-hours calls are handled by the Personal Health Advocate on call.
CARE COORDINATION
The Personal Health Advocate helps members coordinate care among physicians and medical institutions in various ways:
Helping members understand tests, treatments and medications recommended or prescribed by their physician.
Assisting members through a complex medical condition.
Facilitating the transfer of medical records, x-rays and lab results prior to a scheduled appointment with a new physician.
Arranging for home-care equipment following discharge from the hospital.
Facilitating a review of test results with another physician for confirmation of a diagnosis.
Coordinating and making arrangements for diagnostic tests.
Coordinating care for a member with complicated medical issues.
Consolidating a multiple-day testing schedule for special needs members.
Arranging for a member to be evaluated for participation in a clinical trial.
Arranging hospice and other services for terminally ill patients.
Facilitating transfer from a community hospital to a tertiary care facility.
Fostering communication and coordinating benefits between physicians and with insurance companies.
ADVOCATES OF EXCELLENCE™
Helps members with rare, serious or complex medical conditions identify top medical institutions, critical illness providers and specialized medical programs across the country. Our Personal Health Advocates will schedule appointments and coordinate transportation and lodging when necessary.
BENEFITS ADVANTAGE™
Claims Assistance: Personal Health Advocates help sort out and solve claims and related paperwork problems. We work on coverage issues and help members understand the coding and payment rules that apply to their circumstances. Examples of other services include:
Researching a member’s outstanding out-of-pocket responsibilities and resolving errors with providers and/or their health plan.
Correcting balance-billing problems.
Resolving eligibility problems and benefit and claim denials.
Correcting charges incorrectly applied to the member’s deductible.
Resolving questions over whether services are condition specific or related to preventive care.
Coordinating benefits between dental, medical, workers comp and disability carriers.
Resolving incorrect plan procedure interpretations such as emergency room claims denied for a lack of precertification.
Assuring correct application of provider network status.
Correcting errors in processing of “blind” network provider discounts.
Providing payers with additional information required to correctly pay a claim or apply a benefit.
Resolve coordination of benefits disputes between multiple carriers.
Satisfying plan requests for copies of referrals.
Resolving errors in the application of deductibles and co-payments.
Providing the correct member insurance information to providers.
Fee Negotiation: When necessary, Health Advocate can attempt to negotiate fees with healthcare providers to lower the member’s out-of-pocket costs. This is often done prior to the member receiving services. We can also review questionable bills to catch duplicate or erroneous charges.
Grievance Advice: Our first approach is to resolve disputes and issues through discussion; however, when necessary we will provide advice or assistance to members when filing a complaint or grievance with their health insurer or health plan administrator. We can provide the member with guidance regarding their appeal rights and when all other means have failed and we agree that the issues are valid, help the member formulate the argument, gather supporting documentation and write the letter of appeal to the health plan.
COVERAGE ADVANTAGE™
If there are questions of coverage for a particular service, or if coverage for clinical care has been denied, the Personal Health Advocate can help members through the review and appeals process. We can also assist in identifying alternative coverage options when necessary.
Obtaining exceptions for a member to see providers outside of their captivated relationships.
Obtaining referrals for required services.
Locating in-network suppliers and obtaining plan approval for the use of out of network suppliers for necessary healthcare equipment and supplies that are not available from in-network suppliers.
Obtaining transitional care coverage at an in-network benefit level when medically necessary.
Resolving questions of denial of benefits deemed to be non-covered, not medically necessary or ineligible.
Counseling members regarding current benefit costs and the cost of alternatives approaches.
Helping members understand the process for obtaining coverage for medical equipment, devices, supplies. (e.g., hearing aids, diabetic supplies, compression stockings)
Answering coverage questions.
Providing information regarding benefit level coverage comparisons for various providers.
Transitioning members from out of network to in-network providers.
Assisting members with the preauthorization and predetermination process.
Locating “hard-to-find” IV drugs or home care services to facilitate hospital discharge.
Assisting employees with disability coverage questions and helping them back to work.
Resolving eligibility questions involving disabled dependent rules, Family Medical Leave Act, COBRA, etc.
RX ADVOCATE™
The Personal Health Advocate can provide members with assistance on prescription drug issues including formulary and benefit questions.
Providing information for renewing prescriptions.
Providing information on generic drugs.
Locating lower cost sources for prescription drugs that are not covered by the health plan.
Assisting members in obtaining mail order prescriptions.
Resolving questions between members and pharmacies regarding the amount of product requested and the amount dispensed.
Obtaining coverage for medications that require mail order.
HEALTH ADVOCATE CAREQUEST™
Helps locate and makes arrangements for members’ special services needs. The individual member is responsible for payment of any specific services arranged on a fee-for-service basis that are not covered by an insurance plan. Examples of the kind of services we can help members with include:
Locating homemaker, adult day care and rehabilitation services not covered by the member’s health plan.
Locating inpatient private duty nursing.
Finding a group home for individuals with special needs.
Locating home health aides.
Helping members complete qualification applications for individual coverage options, including Medicaid and Medicare.
M.D. Direct™: In the case of serious medical illness, Health Advocate can provide members with access to experts for consultations and second opinions. Every step is taken so that members and their families are advised in full as to the diagnosis, treatment, medications and support systems available to them.
Complementary and Alternative Medicine: Health Advocate helps to identify and coordinate a range of wellness services including those offered by Complementary and Alternative Medicine (CAM) practitioners in areas such as acupuncture, chiropractic care and massage therapy.
Mind Matters™: If necessary, Health Advocate can help members find an appropriate mental health provider to meet their specific needs.
Appeals Representation: When all other means of dispute resolution have failed and we believe that the member’s position is valid, Health Advocate will represent members during the appeals process including attending health plan hearings. (Representation at appeals hearings will be billed at an hourly rate, plus travel expenses, if any.)
Healthy Wheels™: Health Advocate helps arrange transportation services to support our members’ healthcare needs.
Senior Care Navigator: For employees or family members approaching retirement or already retired, we offer access to a wide array of services specifically geared for seniors. Our Personal Health Advocates understand senior members’ needs and can help members select the appropriate professionals. Among the kind of issues we have worked on are:
Locating alternative care facilities.
Obtaining coverage for medical supplies.
Providing information on adult day care programs.
Coordinating coverage for home care services with Medicare and Medicaid.
Assisting with the transition of insurance coverage and benefits from private insurance to Medicare.
Locating physicians who make house calls for people who cannot easily get to the doctor’s office.
Wellness Advantage™: For those members looking for a personalized approach to weight management, getting and staying in shape, stress management, Health Advocate can help locate providers and arrange appointments for these services.
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.
No business can afford to be unprepared for a lawsuit.
Liability insurance protects your business assets when the business is sued for something the business did (or failed to do) that contributed to injury or property damage to someone else.
Liability coverage extends not only to paying damages but also to the attorneys’ fees and other costs involved in defending against the lawsuit, whether valid or not.
The standard business owners policy provides liability coverage, as does a separate policy known as a commercial general liability (CGL) insurance policy.
Generally, commercial liability insurance, whether purchased in a separate policy, or as part of a standard business owners policy, will cover bodily injury, property damage, personal injury or advertising injury. The medical expenses of a person (other than an employee) injured at the business or as a direct result of the operations of the business are also covered.
Usually excluded from both types of liability insurance policies are suits by customers against a business for nonperformance of a contract and by employees charging wrongful termination or racial or gender discrimination or harassment.
Business Group Plans
Types & Uses of Retirement Plans for Business/Group/Employees*
Simplified Employee Pension (SEP) Plan: For self-employed people and small business owners who wish to make tax-deductible contributions of up to $40,000 or 25% of their income, whichever is less, and that of their eligible employees.
Simple IRA Plan: For firms of 100 or fewer employees to establish an employee savings program for pre-tax contributions of up to $7,000 per year.
Profit Sharing Plan (Keogh** Plan): For business owners who wish to make tax-deductible contributions of up to 15% of each participant’s pay, and have vesting and loan schedules not available with a SEP.
Money Purchase Pension Plan (Keogh** Pension Plan): For business owners with predictable incomes who wish to make pre-determined tax-deductible contributions of up to 25% of each Participant’s pay.
Age-Weighted or Comparability Plan: For business owners who are older and more highly paid than most of their employees and wish to allocate contributions under a formula based on both age and salary.
Defined Benefit Pension Plan: For business owners who wish to contribute enough money each year to provide a specific benefit upon retirement. This may be beneficial to older employees with a high, stable income who need a rapid accumulation of assets over a short period of time.
401(k) Plan: For employers who wish to allow employees to make pre-tax contributions through payroll deductions of up to $11,000 per year or 25% of their pay, whichever is less.
Safe Harbor or DASH 401(k) Plan: For business owners who wish to give their employees the advantages of a 401(k) plan, while maximizing the amount they can put away for themselves.
403(b) Plan: For employees of public schools, non-profit hospitals and other certain tax-exempt organizations. Also known as a Tax-Sheltered Account.
Our agency does not provide legal or tax advice. For specific legal or tax advice based on your situation, please contact your attorney of tax advisor.
** The term “Keogh” or “HR-10” describes any type of retirement plan established by an unincorporated business – whether it be a profit sharing, money purchase or defined benefit plan.
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