Q&A

What is a specialty drug?

Specialty drugs are high-cost prescription medications used to treat complex, chronic conditions like cancer, rheumatoid arthritis and multiple sclerosis. Specialty drugs often require special handling (like refrigeration during shipping) and administration (such as injection or infusion). Patients using a specialty drug often must be monitored closely to determine if the therapy is working and to [...]

Q&A

Are employers required by the Affordable Care Act to purchase group insurance for their employees?

Yes, the Affordable Care Act requires large employers to provide coverage to full-time employees or pay a penalty. This provision, called the “play or pay” rule, goes into effect Jan. 1, 2014. Small employers – those with fewer than 50 employees – are exempt from the coverage requirement and penalty. As a side note, be aware [...]

Q&A

What’s the difference between prescription discount plans and prescription drug insurance?

There are two basic and very different types of drug plans: prescription discount plans and prescription drug insurance. In a discount plan, you typically pay a monthly or annual fee and get a card. You present your card when you fill a prescription, and the pharmacy gives you a certain percentage off the cost of [...]

Q&A

What’s the difference between brand name and generic drugs?

You probably know that generic drugs are a lot cheaper than brand name drugs, but you may wonder why. Are they lower quality? Less effective? The FDA requires that a generic drug have the same active ingredient, quality and strength as the brand-name equivalent. The cost difference between brands and generics comes from the cost [...]

Q&A

What is an accountable care organization (ACO) and what will it do?

An accountable care organization (ACO) is a new health care delivery model envisioned by the Affordable Care Act (ACA) in which a group of doctors, hospitals and other health care providers work together to coordinate care for people enrolled in Original Medicare. Many Medicare beneficiaries have several chronic conditions and see several different doctors. As often [...]

Q&A

How can I get health insurance coverage if I have a pre-existing condition?

If you have a pre-existing medical condition and are shopping for health insurance, expect special treatment. How special? Well, kind of like a felon carrying the Ebola virus. You may as well stick a “kick-me” sign on your back. You’ll either be denied coverage, charged extra for premiums and out-of-pocket costs, or you might just have [...]

Q&A

Can I get health coverage for a child with a pre-existing condition?

There’s good news for children with pre-existing conditions who are below the age of 19. Under the Affordable Care Act passed in 2010, they can’t be denied coverage under group plans and most individual family or child-only policies. This applies even if your child has a potentially life-threatening medical condition like asthma or diabetes. This [...]

Q&A

Who should consider a high-deductible health insurance plan?

If you’re healthy and have some money in the bank, you might want to consider a high-deductible health insurance plan. The plans offer cost savings over plans because of the high deductible, and they protect you from catastrophic health events. If you’re in good health, rarely need prescription drugs, don’t have a pre-existing condition and [...]

Q&A

What is a high-deductible health plan?

A high-deductible health insurance plan can provide affordable coverage for unexpected major health and medical expenses. Essentially a form of catastrophic insurance, these plans charge a high annual deductible – from $1,000 to $5,000 and higher – in exchange for lower monthly premiums. You’ll have to pay out-of-pocket costs for routine doctor’s office visits or [...]

Q&A

What are potential drawbacks of a high-deductible health plan (HDHP)?

One significant downside to a high-deductible health plan (HDHP) is that you’re responsible for paying everything out-of-pocket until you reach your deductible (which typically ranges from $1,000 to $5,000 on these plans). You’ll pay 100 percent of the cost of prescriptions, doctor visits and emergency room visits. You’ll also pay for the cost of surgeries [...]

Q&A

What kind of coverage will the plans sold through the health insurance exchanges include?

The Affordable Care Act (ACA) requires that all health insurance plans sold on state exchanges beginning Jan. 1, 2014 cover ten essential benefits: Ambulatory patient services Emergency services Hospitalization Maternity and newborn care Mental health and substance use disorder services, including behavioral health treatment Prescription drugs Rehabilitative and habilitative services and devices Laboratory services Preventive [...]

Q&A

How will the health insurance exchanges affect me if I already have insurance from my employer?

When the exchanges first get up and running, they are designed to provide insurance only to individuals (including families) and to small businesses (one to 100 employees). Eventually, they may expand to offer group insurance to larger employers, but that is up to each state to decide.

Q&A

what happens if I don’t buy health insurance after 2014?

The health reform law includes an individual mandate, requiring every American to have health coverage, with just a few exceptions. It includes a penalty for anyone who does not buy health insurance. The penalties are phased in: the penalty is the greater of $95 or 1% of income in 2014; $325 or 2% of income [...]

Q&A

Will insurance from a state health insurance exchange be cheaper than what I can get on my own now?

It’s hard to know right now how much health plans will cost through the state health insurance exchanges, because that depends on many factors that are undecided in most states. Factors will include: whether the exchange will allow all insurers to participate or choose plans that meet certain criteria; how big the pool of people [...]

Q&A

Will the state health insurance exchanges offer long-term care insurance?

Long-term care insurance helps with the cost of nursing home care and assistance at home for the elderly. While the health reform law included something called the CLASS Act, intended to set up a national long-term care insurance program, the federal government recently decided it could not create that program in a cost-effective way, so [...]

Q&A

Is there any chance I will be turned down for coverage by a health insurance exchange?

The main idea behind health care reform law was to remove the barriers to insurance coverage for most Americans who remained uninsured because of pre-existing conditions or issues of cost. The law removes most of those barriers, so not only can the health plan not turn you down because of a pre-existing condition, it can’t [...]

Q&A

When the state health insurance exchanges are in place, will I still be able to use a broker or get some personal help in choosing a plan?

Many individuals and small businesses turn to a broker to help them buy health insurance, and that can be helpful, given how complicated a purchase it can be. The role of brokers is unclear at this point, and really depends on how each state designs its health insurance exchange. For the most part, an exchange [...]

Q&A

Can small businesses use the health insurance exchanges?

Yes, there will be a health insurance exchange for small businesses, called the Small Business Health Options Program (SHOP). A small business is defined in the law as having between one and 100 employees, though the exchanges may start at one to 50 employees, depending on the state. States can also choose to combine their [...]

Q&A

What are some signs that you’re being drawn into a health insurance scam?

Health insurance scams are on the rise as the economy slumps and confusion reigns over health care reform. It’s become one of America’s largest taxpayer rip-offs. “Passage of the legislation designed to protect consumers ironically has given criminals ideas for schemes to swindle uninformed consumers,” says healthinsurance.org founder Charles Smith Dewey. “Now, more than ever, [...]

Q&A

What’s the difference between dental insurance and dental discount plans?

Dental insurance plans work like health insurance. You or your employer pay a monthly premium. After the deductible is reached, the insurance pays all or part of qualified dental expenses, up to a stated maximum. The insurance company pays the dentist directly for its share of your dental expenses. Like health insurance, these plans come [...]

Q&A

What is a health savings account (HSA)?

Want to save 50 percent on your health insurance? Make your medical expenses tax deductible? Cut your taxes $2,000 or more? Take a look at a health savings account (HSA), which combines a tax-deductible savings account with a lower cost high-deductible insurance plan. An HSA allows you to legally avoid federal income tax by depositing [...]

Q&A

Dread disease policies: are they ghoulish?

No, they’re not ghoulish. But they may be superfluous. Individual and group health insurance usually covers all diseases, including dread diseases. Specified disease policies, called “dread disease polices,” pay benefits – usually in a lump sum – only when you’re diagnosed with a specific illness, such as cancer, heart disease or stroke. Typically, designed to [...]

Q&A

What is short-term health insurance?

Designed for healthy individuals and families, short-term policies provide an affordable safety net while switching from one life event to another without a health plan. Lose your job, recent college graduate, divorced, or retired and not quite eligible for Medicare? Then consider short-term insurance. These plans generally cover you for one to six months and [...]

Q&A

Can you keep your 20-something children on your insurance policy?

The Affordable Care Act requires that – as of September 23, 2010 – most health insurance plans cover adult children up to age 26 on their parents’ policy. It applies to both married and unmarried children, but not to their spouses or children. So it makes sense that you’re allowed to keep them on your [...]

Q&A

Why should I consider a catastrophic health insurance policy?

Catastrophic health insurance is another kind of consumer-driven health plan­­ – like health savings accounts (HSAs) and “dread disease” insurance­­­­­ – that can protect you from catastrophic medical and hospital expenses involving major medical bills. It is sometimes referred to as a High Deductible Health Plan (HDHP) because low monthly premiums are traded for a [...]

Q&A

Should I be leery of short-term health insurance policies?

Short-term health insurance plans can be a relatively inexpensive option for individuals who need temporary coverage. But think of the policies as a last resort – a safety net to that could spare you huge medical bills from unforeseen ailments or injuries. Here are some factors you should definitely consider before you buy short-term health insurance [...]

Q&A

How should consumers grade their state’s health insurance exchange?

There are a number of ways to assess your state’s planning and progress toward implementation of a state health insurance exchange. For some constituents, it might be enough simply to know whether the state is moving forward or refusing to budge outright. But one consumer advocacy group – the U.S. PIRG (Public Interest Research Groups) [...]

Q&A

Will every state have a health insurance exchange?

Every state is expected to have a health insurance exchange by 2014 under the Affordable Care Act’s provisions. The law dictates that by 2013, states must demonstrate that they’re actively planning to set up and administer their own health insurance marketplace. If a state can’t prove that it’s on track by 2013, it is opening [...]

Q&A

I have difficulty understanding my hospital bills. Are they usually accurate?

Hospital bills are not only notoriously inaccurate, they’re written in code. According to the experts more than 90 percent of hospital bills contain errors and nearly 70 percent of those errors result in overpayments. A single error can cost you thousands of dollars. No wonder medical bills rank second among reasons for filing bankruptcy. To [...]

Q&A

Do I need special health insurance when traveling abroad?

Most health insurers — including basic Medicare — don’t cover any costs outside the country. Some insurance policies do (Including some Medicare Advantage plans), but with limitations. Ask your current insurer if your policy covers you and your family while traveling abroad. If not, consider supplemental insurance, available for as little as a few dollars [...]

Q&A

Is medical tourism safe?

Medical tourism is not only safe, but treatment abroad can be 40 to 90 percent less expensive than most medical, dental or elective procedures performed in the United States. The idea of heading abroad for medical care is becoming as ordinary as owning a German or Japanese automobile, according to Josef Woodman, author of the [...]

Q&A

Do health insurance policies cover maternity care?

Not unless you work for a large employer. Individual health insurance policies generally don’t cover maternity care. According to a recent Congressional investigation based on responses from the four largest for-profit health insurers, it found that individual policies didn’t cover most of the expenses for a normal delivery. A similar national study in 2009 found [...]

Q&A

What’s the difference between an electronic medical record and an electronic health record?

Because electronic health records and electronic medical records are sometimes mentioned in the same conversation, consumers often believe they’re the same thing. In truth, an electronic medical record is a record kept by one health care provider to document a patient’s treatment and health history. An electronic health record is a long-term look at a patient’s [...]

Q&A

What is the major difference between group and individual insurance?

The major difference between group and individual health insurance involves evidence of insurability. To purchase individual insurance, a person must generally answer a health questionnaire and undergo a medical examination to provide evidence of insurability to the insurance company. An insurer may decline coverage on the basis of the applicant’s personal habits, health, medical history, [...]

Q&A

What are the various ways that individuals receive health insurance protection?

Besides participating in group insurance plans, individuals may also be covered under federal and state government-sponsored programs such as Medicare and Medicaid, service-type plans such as Blue Cross/Blue Shield or so-called alternative health care systems such as health maintenance organizations (HMOs) and preferred provider organizations (PPOs). Insurance may also be purchased privately on an individual basis, or through mass purchasing groups such as credit unions and professional or trade associations.

Q&A

What are the advantages of group insurance over individual insurance?

For an employer that intends to provide insurance protection to its employees, the group approach ensures that all employees, regardless of health, can be covered. Those with known health problems, who might otherwise be unable to obtain individual insurance, can be covered automatically upon employment without evidence of insurability. Although some limits may be imposed on [...]

Q&A

What types of group protection do most employers provide?

Although there are many variations of each, the four major types of insurance coverage provided by employers to their employees are life, accidental death and dismemberment (A D & D), disability and health or medical. Some employers also provide additional coverages, including group legal, travel accident and vision and dental care.

Q&A

How can a labor union provide group insurance?

A labor union can provide group insurance for its members under a policy issued to the union. The union is the policyholder, just as the trust is the policyholder under a multiple employer trust (MET). A union may purchase a group policy for a large number of members who are employed by the same company, or [...]

Q&A

What is a health maintenance organization (HMO)?

A health maintenance organization (HMO) is a form of managed care that provides comprehensive health care to a voluntarily enrolled population at a predetermined price. Members pay fixed, periodic fees directly to the HMO and in return receive health care services as often as needed.

Q&A

What is a preferred provider organization (PPO)?

A preferred provider organization (PPO) is an association that contracts with a group of doctors, dentists, hospitals or other health care service providers to provide care at prearranged rates or discounts.

Q&A

Can an employer work directly with an insurance company?

It is possible for an employer to deal directly with an insurer through a group sales representative to purchase group insurance. Premium rates and underwriting practices vary considerably from one insurer to another, however. In addition, the coverages provided are rarely identical. This means that comparison shopping is often beyond the capability of all but the [...]

Q&A

What is a risk?

The risk an insurance company assumes when it agrees to cover a particular group is the possibility that claims will exceed the expected level. It is the chance of financial loss inherent in the group. Insurance companies use it to determine whether they will underwrite an insurance policy on a particular group. The spread of [...]

Q&A

Who is an eligible employee?

An eligible employee is any employee who meets the definition in the plan for participation. Definitions of eligible employee vary widely from employer to employer, though they may be influenced by legal considerations and company structure.

Q&A

Will an insurance carrier deny certain employees coverage under a group health insurance plan?

Generally, insurers will not deny coverage to any full-time employee. Inherent in the principle of group insurance is the understanding that all employees can be covered. Most carriers, however, require an employee to be actively at work on the day the employer-provider coverage becomes effective, and to have enrolled in a contributory plan within the [...]

Q&A

Are employers required by federal law to purchase group insurance for their employees?

Presently, no federal law requires employers to provide their employee with group insurance. There have been initiatives in Congress, however, that would require employers to provide specified minimum levels of health benefits, and there is every likelihood that some form of national standard will be legislated in the next few years.

Q&A

What is a mandate benefit?

A mandate benefit is a specific coverage that an insurer is required to include in its contract under state law. For example, most states require that coverage for substance-abuse treatment be provided. Other kinds of coverage that are mandated in some states include coverage for newborn children, mental and nervous disorders and hospice care.

Q&A

What are the minimum and maximum number of employees allowed by state law to participate in a group health insurance plan?

Most states require that an employer enroll a minimum number of employees (generally ten, though fewer in some states) for coverage in order to purchase and maintain a group health insurance plan. This minimum size requirement reduces the potential for adverse selection. There is no legal limit to the number of employees that may be [...]

Q&A

What is a base plus plan?

A base plus plan is a two-part health insurance plan. Basic medical coverage — for such expenses as hospitalization, surgery, physician’s visits, diagnostic laboratory tests and x-rays — is provided under the first part. There may be limits on these expenses, such as a limited number of hospital days and a surgical schedule, but no [...]

Q&A

What are the advantages to a base plus plan?

From the employee’s point of view, base plus plans appear to provide more generous benefits because of the lack of deductibles and coinsurance in the basic medical part.

Q&A

What is a comprehensive plan and what are its advantages?

A comprehensive plan provides coverage for most medical services using one reimbursement formula. In a pure comprehensive plan, a deductible must be met before reimbursement for any covered expenses begins, and coinsurance applies to all covered expenses until the maximum employee out-of-pocket expense limit is reached. Additional covered expenses are paid in full. Because employees [...]