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Health Insurance FAQ’s



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QUESTION:
What is the difference between Group Health Insurance Plans and Individual Health Insurance Plans?

ANSWER:
Group health insurance is a policy that is purchased by an employer and offered to eligible employees as a benefit of working for that company. Federal law mandates that no matter what health conditions members may have, no individual employee can be turned down by an insurance company for group coverage. This requirement is known in the insurance industry as “guaranteed issue.” Group insurance companies are also required to give employees credit for prior coverage against any pre-existing condition waiting period that may be imposed, as long as the employee had other health insurance coverage within 63 days of the application for new coverage.

Individual health insurance is different from group health insurance. The laws that mandate the types of services that must be included in individual policies are often different than those for group policies. Benefits of individual plans are generally less extensive than group plans. Benefits are often simpler and deductibles and co-insurance are generally higher in individual policies.

Individual health insurance companies are more limited than group insurance companies in their ability to spread risk, so this means that applicants will need to complete a brief health questionnaire when applying for benefits. Unlike group insurance companies, individual health insurance companies can decide not to cover people with serious medical conditions, deeming them “uninsurable.” The laws concerning individual health insurance differ from state to state.
 


QUESTION:
What is an HMO?

ANSWER:
HMO is a Health Maintenance Organization. As a member of an HMO, you select a primary care physician from a list of doctors in that HMO’s network. Your primary care physician will be the first medical provider you call or see for a medical condition. He or she will make any needed referrals to a medical specialist. Typically, these specialists will be part of the HMO network. If you obtain care without your primary care physician’s referral or obtain care from a non-network member, you will be responsible for paying the entire bill. Normally HMOs have a co-payment for the visit or service. This is the most restrictive type of plan.
 


QUESTION:
What is a POS?

ANSWER:
POS is a Point-of-Service Plan. It is a type of managed care plan that is an HMO with an out of- network option. You can decide whether to go to a network provider and pay a flat dollar or to an out-of-network provider and pay a deductible and/or a coinsurance charge.
 


QUESTION:
What is a PPO?

ANSWER:
A PPO Plan, or a Preferred Provider Organization, is a type of managed care coverage based on a network of doctors and hospitals that provides care to an enrolled population at a pre-arranged discounted rate. PPO members can use doctors outside of the network but they will usually pay more when they choose to go outside the PPO network. If you decide to see a nonparticipating provider, you should know the out-of-network benefits. Your share of the cost would be the out-of-network deductible, plus the coinsurance amount, plus the balance billing amount.

What is the balance billing amount? This is the difference between the billed amount and the contracted amount. For example, your doctor bills $500 for a service, however your insurance contracted amount (or allowed benefit) is $250. Assuming that your deductible has been satisfied and you have a 70%/30% PPO Plan, your out-of-network benefit pays 70% of the $250. So, you would be responsible for 30% of the $250 contracted amount which is $75. Add the balance billing amount of $250 and your total out-of-pocket payment is $325. To minimize your out-of-pocket expenses, it is important to try to see a participating provider in your plan’s network.
 


QUESTION:
What is an Indemnity Plan?

ANSWER:
An Indemnity Plan is commonly known as a fee for service or traditional plan. If you select an Indemnity plan you have the freedom to visit any medical provider. You do not need referrals or authorizations; however, some plans may require you to precertify for certain procedures. Most indemnity plans require you to pay a deductible. After you have paid your deductible, indemnity policies typically pay a percentage of “usual and customary” charges for covered services; often the insurance company pays 80% and you pay 20%. Most plans have an annual out of pocket maximum and once you’ve reached this they will pay 100% of all “usual and customary” charges for covered services. Many health insurance companies have moved away from indemnity plans. This is the least restrictive, therefore the most expensive type of health plan.
 


QUESTION:
What is HIPAA?

ANSWER:
The Health Insurance Portability and Accountability Act, better known as HIPAA, amended the Employee Retirement Income Security Act (ERISA) in 1996, to provide new rights and protections for participants and beneficiaries in group health plans. Understanding this amendment is important to your decisions about future health coverage.HIPAA includes protections for coverage under group health plans that:

  • limit exclusions for pre-existing conditions;
  • prohibit discrimination against employees and dependents based on their health status; and,
  • allow a special opportunity to enroll in a new plan to individuals in certain circumstances.

HIPAA requires that group health plans give credit for prior coverage. You will receive credit for previous healthcare coverage, as long as you do not have a break in credible coverage of 63 or more days. This is called credible coverage. COBRA coverage also counts as credible coverage as long as you do not have a break in coverage of 63 or more days between COBRA coverage and the group health insurance plan.

In other words, as long as you do not go without insurance for 63 days or more, the insurance company cannot enact the pre-existing condition clause. It is important for you to know your benefits and to understand if your treatment needs to be preauthorized by your provider before rendering services.

For additional information on the HIPAA, go to the Department of Labor’s Employee Benefits Security Administration at http://www.dol.gov/ebsa and click the FAQ tab on the left side of the page.
 


QUESTION:
What is COBRA?

ANSWER:
COBRA, the Consolidated Omnibus Budget Reconciliation Act, gives workers who lose their health benefits the right to choose to continue group health benefits provided by their plan under certain circumstances.
The employer will send an election notice within 14 days after the employee’s last day on the health insurance plan. The employee will then have 60 days to decide whether to elect COBRA continuation coverage. The employee will then have 45 days after electing coverage to pay the initial premium. Expect to pay the total premium (the employer + employee contribution) plus 2% for administration. Also, another important note is that the premiums are not tax deductible, like they are when they are deducted from payroll.

There are certain qualifying events that would cause an individual to lose health coverage. The type of qualifying event will determine who the qualified beneficiaries are and the amount of time that a plan must offer the health coverage to them under COBRA. A plan, at its discretion, may provide longer periods of continuation coverage.

Qualifying Events for Employees:

  • Voluntary or involuntary termination of employment for reasons other than gross misconduct
  • Reduction in the number of hours of employment

Qualifying Events for Spouses:

  • Voluntary or involuntary termination of the covered employee’s employment for any reason other than gross misconduct
  • Reduction in the hours worked by the covered employee
  • Covered employee’s becoming entitled to Medicare
  • Divorce or legal separation of the covered employee
  • Death of the covered employee

Qualifying Events for Dependent Children:

  • Loss of dependent child status under the plan rules
  • Voluntary or involuntary termination of the covered employee’s employment for any reason other than gross misconduct
  • Reduction in the hours worked by the covered employee
  • Covered employee’s becoming entitled to Medicare
  • Divorce or legal separation of the covered employee
  • Death of the covered employee

 


QUESTION:
What is the difference between co-pay and a coinsurance?

ANSWER:
A co-pay requires the insured to pay a specified amount of out-of-pocket expenses for health care services such as doctor visits and prescriptions drugs at the time the service is rendered, with the insurer paying the remaining costs. Co-pay fees will vary among insurers but are typically very affordable. For example, a co-pay plan may require the insured to pay $25 per doctor visit or $10 per prescription up to a specified coverage limit.

With a coinsurance, a health plan will require you to pay a percentage rate meaning that you will essentially be splitting the cost of your healthcare with the insurance carrier. For instance, if the health plan has an 80/20 coinsurance rate, the insurance plan pays for 80% of the eligible medical expenses and you are responsible for the remaining 20%.
 


QUESTION:
What are some of the important health care reform changes that have already gone into effect as a result of The Patient Protection and Affordable Care Act (PPACA)?

ANSWER:

  • Adult children may remain as dependents on their parents’ policy until their 26th birthday.
  • Children under age 19 may not be excluded for pre-existing conditions.
  • No more lifetime or annual caps on health coverage.
  • Free preventative care for all people.
  • The “doughnut hole” is in the process of closing for Medicare patients, making prescription medications more affordable for seniors.
  • Insurance plans are available for persons who have not been able to purchase medical insurance because of a pre-existing condition.

 


QUESTION:
What are some tips for applying for Social Security Disability?

ANSWER:

  • When filing a claim, it is best to obtain the most current records from your relevant treating sources, for example, your immunologist, rheumatologist, etc., and submit them at the time of the application. This will help expedite your claim. You should also obtain letters from your treating physician and other specialists with supporting objective evidence such as lab findings, MRIs, x-rays, etc stating that you are unable to sustain a 40 hour workweek. This will greatly support your claim.
  • Stay in contact with your disability examiner every 10-14 days. Their name and phone number should be located on the mail they send to you. Ask them if they have received all your pertinent medical records. Most hospitals and physicians’ offices rely on copy services which only come by once a week. It may take several phone calls/faxes to obtain the needed information which could make a huge difference in your claim.
  • When Disability Determination Services (DDS) sends you forms to complete regarding how pain affects your activities, fatigue, etc you should be as detailed as possible and don’t be afraid to add extra sheets to the forms. Describe a typical day when completing an activity of daily living form. You will also be asked to complete a work history form. This should include the jobs you worked in the last 15 years. Please be as detailed as possible regarding your job duties, rate of pay, supervisory duties, etc.
  • You may be asked to attend a medical exam at no expense to you to in order to obtain more information. This is more common in cases such as rheumatoid arthritis, SLE, fibromyalgia etc when detailed joint range of motion and mobility/gait information is needed in addition to the information about your PIDD. It is very important that you keep this exam. Your disability examiner will contact you by phone or mail regarding the details of the exam.

For more detailed information, please go to the Social Security Administration Website: www.ssa.gov.
 


QUESTION:
What questions should I ask before selecting a new insurance plan?

ANSWER:
IDF created the IDF Health Insurance Toolkit to provide you with information, facts, resources and worksheets to help you choose the best possible options for you and your family. You can find a complete list of questions to ask before selecting a health insurance plan at http://primaryimmune.org/wp-content/uploads/2013/10/IDF-Health-Insurance-Toolkit-Revised-Oct.-2013.pdf

Some items to consider:

  • Will the policy cover intravenous (IVIG) or subcutaneous (SCIG) immunoglobulin treatment?
  • Are there particular locations that I have to get my treatment? Do they differ based on whether it is SCIG or IVIG?
  • Can I get my IVIG done at home?
  • Is there an annual deductible? If so, how much is it?
  • Is there a co-pay or co-insurance that must be paid for IVIG or SCIG treatment? If so, how much or what percentage?
  • What is my maximum out of pocket expense each year? (In other words, what is the most I will have to pay each year?)
  • Is there a waiting period before a pre-existing condition or illness will be covered and services paid for? If so, how long? Also, can it be waived?
  • Will the policy allow for use at both an “in-network” and “out-of-network” provider, physician, and pharmacy? If so, what are the differences in cost?

 


QUESTION:
Is IVIG or SCIG treatment covered under Medicare Part B or Part D?

ANSWER:
If you have a primary immunodeficiency disease with the diagnosis codes 279.04, 279.05, 279.06, 279.12, or 279.2, your IVIG/SCIG treatment is reimbursed under Medicare Part B. If your provider submits the IVIG/SCIG service claim under Part D, it will most likely be denied. Your provider will have to reprocess and submit those IVIG/SCIG claims through Medicare Part B.

In some cases, a Medicare Advantage plan may cover other primary immunodeficiency disease diagnosis codes under Part D. You should check with your Medicare Advantage provider to see how they are processing your claim.
 


QUESTION:
What are some tips for dealing with an insurance denial for my immunoglobulin (IG) replacement therapy?

ANSWER:
Below are some “how to” tips from a clinical immunologist that has been successful in overturning IG denials. This is followed by a link to the IDF website that includes additional information including sample appeal letters that should be tailored to the patient’s clinical history.

The appeal should be short, succinct and carefully documented.

  • Keep in mind that you have 2 minutes of the Medical Director’s attention.
  • Provide well-accepted diagnostic studies which are in the practice guidelines.
  • Provide standards of practical criteria to support the laboratory studies.
  • Provide proof and documentation of serious infections/complications which have not been responsive to appropriate medical/surgical intervention; including clear radiographic evidence of persistent disease, e.g. lungs, sinuses et al, clinical documentation of infections etc.
  • Focus on the rationale for immunoglobulin therapy – a doctor’s letter that states “because it is medically necessary” is not specific enough to be added to an appeal letter. Precise statements are required. . . for example: 3 episodes of pneumonia with fever to 102. Chest x-ray (if available) showed lobar pneumonia and xx days of antibiotics were required.
  • Keep in mind that the insurance companies are reviewing thousands of appeals; therefore, the larger packets, will be put to the side. The shorter the appeal, the shorter the turn-around-time for a response.
  • When concluding the letter, add the names of the immunologists that have completed the scientific research on the diagnosis in question, should the insurer request a peer review. For example “Should you have any questions, I would request a peer review by either Dr. John Smith or Dr. Ann Jones from the University School of Medicine”

Click here for more information to share with your healthcare professional.
 


QUESTION:
Can I itemize medical deductions on my federal tax return if I already received reimbursement for those expenses from my healthcare flexible spending account (FSA)?

ANSWER:
If you did not have a FSA, you would be able to claim certain medical expenses as deductions on your taxes. However, since you do have an account, taxes were never taken out of your FSA contributions. For that reason, medical expenses paid for with FSA money cannot be included on your tax return. You should speak with a tax consultant when determining what expenses are eligible for deduction.