Transcript Insurance Coverage: Knowing What you Have and How to Keep It

Insurance Coverage:
Knowing What You Have
and
How to Keep It
Sally McCarty
Orlando, Florida
June , 2008
Know Your Health Plan
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Traditional Indemnity?
PPO?
HMO?
Employer Group?
Small Employer Group?
Individual?
Other Type of Coverage?
Traditional Indemnity Plans
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Reimburse enrollees for covered expenses incurred
due to sickness or injury.
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Expenses are reimbursed after:
– coinsurance (percentage share of cost for which
the enrollee is responsible) and
– deductible (annual amount of out-of-pocket that
must be paid by enrollee before benefits begin)
amounts are met.
Preferred Provider Organization
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Payment mechanism is the same as traditional
indemnity.
Expenses are reimbursed after coinsurance
and deductible amounts are met.
Coinsurance is higher when services are
provided outside of plan’s provider network.
No referral process is required.
HMO
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Enrollees must choose a physician as their primary
care physician (PCP).
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Founded on the premise that covering preventive care
while controlling costs will result in better health care
and lower rates of health care inflation.
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PCP is the "Gatekeeper" for all medical services.
Employer Group
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Subject to HIPAA protections
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Limits to pre-existing condition exclusions
Non-discrimination provisions apply
More…
If more than 20 employees, subject to COBRA
If Small Employer Group, subject to HIPAA
Guaranteed Issue
Non-Discrimination Provisions
Under HIPAA, you can’t be charged more or removed
from a group plan due to:
 Health status
 Genetic information
 Claims experience
 Receipt of health care
 Medical history
 Evidence of insurability
 Disability
 Medical condition -physical & mental illness
Individual (Non-Group) Coverage
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Coverage that is sold by health insurance issuers or
HMOs to individuals/families who are not part of a
group health plan.
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Might be provided through an association or other
group, such as college students or self-employed
individuals.
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Only HIPAA Protection is guaranteed renewability.
Options When Losing Coverage
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COBRA
Florida Small Group Conversion Policy
Trade Adjustment Assistance
HIPAA Eligible – guaranteed issue of an
individual policy or a group conversion policy
Self-employed (one-life groups) open
enrollment
COBRA
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Are you eligible for COBRA?
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Your employer has 20 or more employees
Employment terminates for other than gross misconduct
102% of Total Premium (Employer + Employee share)
18 months of coverage – up to 36 in some circumstances
Qualifying event:
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Spouse of employee who becomes eligible for Medicare
Divorce or legal separation from covered spouse
Death of covered spouse
Loss of dependent child status under plan rules
60 Days to Sign Up
Florida Small Group Conversion
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your employer has fewer than 20
employees
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By Florida law, you have a right to pay
for continuation coverage for 18
months.
Trade Adjustment Assistance
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A federal law called the Trade Adjustment Assistance
Reform Act may pay 65% of the cost of your health
insurance for up to 3 years:
– If you recently lost your job because of imports or
jobs moving overseas,
– If you are a retiree aged 55 or older, your former
employer no longer provides your pension, and your
pension benefit is paid by the federal Pension
Benefits Guaranty Corporation,
HIPAA Federally Eligible
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At least 18 months of continuous creditable coverage.
Most recent coverage under a group plan.
Not eligible for another group health plan.
Most recent coverage not cancelled due to
nonpayment of premiums or fraud.
Not eligible for Medicare or Medicaid.
COBRA or state continuation coverage exhausted.
Did not accept a conversion or short-term limited
duration policy.
Florida HIPAA Eligibles
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Leaving a Group Plan
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Employer required to offer a conversion plan
– Premium can be up to 200% of standard risk
– Benefits determined by Florida regulation
Carriers in the individual (non-group) health insurance
market must guarantee issue their two most popular
currently marketed plans to HIPAA-qualified persons
leaving a self-funded plan.
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Self-employed Guarantee Issue
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Florida requires its small group carriers (e.g.,
carriers selling health insurance in the small
group market) to:
– Offer insurance on a guaranteed issue basis
each August to self-employed individuals
(one-life groups)
– The carriers can charge up to 150% of their
standard rate for these individuals.
ASSESS YOUR NEEDS
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Which benefits are the most essential for you
or your family?
Does the plan provide access and adequate
coverage for the specialists and the specific
treatments you and your family need?
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Will the location of the plan’s network doctors make
transportation an issue?
How is Factor Covered?
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Is Factor coverage a medical or pharmacy benefit?
If a pharmacy benefit, are there separate annual
benefit caps for pharmacy?
If a pharmacy benefit, are there separate benefit limits,
out-of-pocket maximums, or copayments for factor?
If a medical benefit, are there separate benefit limits,
out-of-pocket maximums, or copayments for specialty
injectables?
Under either option, what are the coinsurance
percentages or co-payments for clotting factor?
Insurance Needs for Families Dealing
with a Bleeding Disorder
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INCREASE OR ELIMINATE LIFETIME CAPS.
The average $1 million lifetime cap established by the
insurance industry in 1970 would equal $18 million today if
indexed for inflation
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ASSURE THAT OUT-OF-POCKET MAXIMUMS (OOPs) APPLY TO
SPECIALTY INJECTABLES.
20% coinsurance with no OOP will certainly drain an average
family’s savings without a limit on OOPs for that category
Insurance Needs, continued
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Access to:
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Medically prescribed and cost efficient health care
Exact brand and quantity of clotting factor
prescribed by physician
Other necessary ancillary services necessary for
optimum care
Providers who follow minimum standards of care in
handling and delivery of factor and other health care
services
Be Alert For:
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Insurers cutting costs by:
Tiered Drug Plans
– Separate Out-of-Pocket Maximums or
Annual Caps for Specialty Injectables
– Additional restrictions on provider networks,
especially pharmacy/home health providers
– Many other “creative” means to cut costs are being
employed – especially by ERISA plans
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Need Help?
Health Plans:
 Florida Office of Insurance Regulation
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Toll Free:1.800.342.2762
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Web Site: www.floir.com.
Self-funded ERISA plans: www.dol.gov/ebsa
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Click on one of the following:
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Compliance Assistance
Consumer Information
FAQs
Contact Us
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Need Help?
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U.S. Department of Labor’s “Frequently Asked
Questions about COBRA Continuation
Coverage”
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Web site:www.dol.gov/ebsa/faqs/faq_consumer_cobra.html
Toll free 1.866.275.7922
Need Help?
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Trade Adjustment Assistance Act
– Health Coverage Tax Credit (HCTC)
Customer Contact Center:
 Toll-free 1.866.628.HCTC
 Web site:
www.irs.gov/pub/irs-utl/hctc_program_kit_07-05.pdf.