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How do you stay
up to date with the latest changes and new plans in the
ever changing insurance marketplace?
Our
brokers are licensed and regulated by the Virginia
Department of Insurance. Continuing Education
classes are only part of their efforts to stay on top of
the latest developments in insurance law and
application. They also take part in seminars,
educational workshops and up to the minute briefings by
professional organizations, such as the National
Association of Health Underwriters (NAHU), as well as
training provided by the companies with which we do
business. Furthermore, they consult professional
magazines and newsletters to stay apprised of
marketplace developments and trends.
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What is a
deductible?
A health insurance deductible
is the amount of the loss, which the insured person must
pay out of pocket for a covered expense before the
insurance company will pay any compensation. Such
deductibles, for instance $500, must be sustained and
paid by you each plan year before the insurance carrier
is responsible for any covered medical expenses. Keep in
mind that expenses that are not covered by your health
insurance policy do not count toward your
deductible.
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What is a copayment?
A
copayment is a partial payment the insured is required
to pay for certain medical services, for instance a
physician office visit or a prescription drug.
Co-pay fees are usually listed on the insured’s
participant ID card.
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What is
reasonable and customary?
Insurance
companies often pay claims based on the “usual &
customary“ fee charged by medical providers in a
geographic area for a particular service. The fee
is based on what most other hospitals, labs or
physicians in a pre-determined geographic area are
charging for similar services/procedures.
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What is the
difference between Fee for Service and Managed Care
Plans?
Fee for
Service plans also known as Indemnity
Plans and Managed Care plans differ in their basic
approach. Put broadly, the major differences concern
choice of providers, out-of-pocket costs for covered
services, and how bills are paid. Usually, indemnity
plans offer more choice of doctors (including
specialists, such as cardiologists and surgeons),
hospitals, and other health care providers than managed
care plans. Indemnity plans pay their share of the costs
of a service only after they receive a
bill.
Managed Care plans
have agreements with certain doctors, hospitals, and
health care providers to give a range of services to
plan members at reduced cost. In general, you will have
less paperwork and lower out-of-pocket costs if you
select a managed care type plan and a broader choice of
health care providers if you select an indemnity-type
plan.
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Besides
indemnity plans, there are basically three types of
managed care plans: PPOs, HMOs, and POS
plans:
Fee For Service
(Indemnity Plan):
With an indemnity plan
(sometimes called fee-for-service), you can use any
medical provider (such as a doctor and hospital). You or
they send the bill to the insurance company, which pays
part of it. Usually, you have a deductible—such as
$200—to pay each year before the insurer starts
paying.
Once you meet the deductible, most indemnity
plans pay a percentage of what they consider the "Usual
and Customary" charge for covered services. The insurer
generally pays 80 percent of the Usual and Customary
costs and you pay the other 20 percent, which is known
as coinsurance. If the provider charges more than the
Usual and Customary rates, you will have to pay both the
coinsurance and the difference.
The plan will pay
for charges for medical tests and prescriptions as well
as from doctors and hospitals. It may not pay for some
preventive care, like checkups.
Managed
Care:
Preferred Provider
Organization (PPO)
A PPO is a form of
managed care closest to an indemnity plan. A PPO has
arrangements with doctors, hospitals, and other
providers of care who have agreed to accept lower fees
from the insurer for their services. As a result, your
cost sharing should be lower than if you go outside the
network. In addition to the PPO doctors making
referrals, plan members can refer themselves to other
doctors, including ones outside the plan.
If you go
to a doctor within the PPO network, you will pay a
copayment. Your coinsurance will be based on lower
charges for PPO members.
If you choose to go outside
the network, you will have to meet the deductible and
pay coinsurance based on higher charges. In addition,
you may have to pay the difference between what the
provider charges and what the plan will
pay.
Health Maintenance Organization
(HMO)
HMOs are the oldest form of managed
care plans. HMOs offer members a range of health
benefits, including preventive care, for a set monthly
fee. There are many kinds of HMOs. If doctors are
employees of the health plan and you visit them at
central medical offices or clinics, it is a staff or
group model HMO. Other HMOs contract with physician
groups or individual doctors who have private offices.
These are called individual practice associations (IPAs)
or networks.
HMOs will give you a list of doctors
from which to choose a primary care doctor. This doctor
coordinates your care, which means that generally you
must contact him or her to be referred to a specialist.
With some HMOs, you will pay nothing when you
visit doctors. With other HMOs there may be a copayment,
like $5 or $10, for various services.
If you
belong to an HMO, the plan only covers the cost of
charges for doctors in that HMO. If you go outside the
HMO, you will pay the bill. This is not the case with
point-of-service plans.
Point-of-Service
(POS) Plan
Many HMOs offer an
indemnity-type option known as a POS plan. The primary
care doctors in a POS plan usually make referrals to
other providers in the plan. But in a POS plan, members
can refer themselves outside the plan and still get some
coverage.
If the doctor makes a referral out of the
network, the plan pays all or most of the bill. If you
refer yourself to a provider outside the network and the
service is covered by the plan, you will have to pay
coinsurance.
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What is a
preexisting condition?
This is normally a
physical or mental condition for which medical advice,
diagnosis, care or treatment is recommended or received
before the effective date of the policy. The definition
can vary from policy to policy.
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What is
a Certificate of Creditable Coverage?
A
document provided by your health plan that lets you
prove you had coverage under that plan. Certificates of
creditable coverage will usually be provided
automatically when you leave a health plan. You can
obtain certificates at other times as well.
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What is a Primary Care Physician (PCP)?
Your primary care doctor will serve as your
regular doctor, managing your care and working with you
to make most of the medical decisions about your care as
a patient. In many plans, care by specialists is only
paid for if you are referred by your primary care
doctor.
An HMO or a POS plan will provide you
with a list of doctors from which you will choose your
primary care doctor (usually a family physician,
internists, obstetrician-gynecologist, or pediatrician).
This could mean you might have to choose a new primary
care doctor if your current one does not belong to the
plan.
PPOs allow members to use primary care
doctors outside the PPO network (at a higher cost).
Indemnity plans allow any doctor to be used.
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Can my employer change our health
insurance carrier and level of benefits during the year?
Yes. It is completely up to the employer
whether or not they will offer health insurance to
employees at all and they can change carriers and level
of benefits at any time.
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Does the Waiting Period required by an
employer before an employee becomes eligible for health
insurance count toward the preexisting condition
exclusion period?
Waiting periods do not
count as gaps in health insurance for purposes of
determining whether coverage is continuous. If your
employer requires a waiting period, your preexisting
condition exclusion period begins on the first day of
the waiting period. See also Preexisting
Condition Exclusion Period.
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What happens when my group health
coverage ends?
You can apply for individual
health coverage under the federal law Health Insurance
Portability and Accountability Act (HIPAA). This type of
policy is issued on a guaranteed issue basis if you meet
the qualifying criteria. However, there is no limit on
the maximum premium the company can charge. Preexisting
conditions are waived.
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Can health insurance companies deny an
application for individual insurance due to a health
condition?
Yes, the company has the right
to deny coverage for almost any reason on a new
application. However, once you are accepted for
coverage, your policy can only be terminated for one of
two reasons. The company can cancel your policy if you
fail to pay your premiums in a timely manner. If you
misrepresent information on the application or fail to
disclose known information, the company may rescind the
policy for material misrepresentation.
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What is
term life insurance?
Term insurance
provides protection for a specified period of time; a
term of 1, 5, 10 or 20 years or up to age 65 is
available. This type of policy only pays a benefit if
you die during the policy term. Term insurance does not
build cash value. If you stop paying your premium, the
insurance expires. This insurance generally is less
expensive than other types of life insurance.
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What is whole life insurance?
Whole life insurance is meant to be kept in
force throughout your entire life. An important feature
of whole life insurance is the accumulation of cash
value. The cash value is the cash available to borrow
against the policy, or the value of the policy paid to
the policy owner when the contract is surrendered before
maturity. Any withdrawal of cash value is treated as a
policy loan and interest accumulates based on the loan
amount. If you do not pay back the loan, the death
benefit is reduced by the outstanding loan amount.
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What is an annuity?
An
annuity pays a monthly (or quarterly, semi-annual, or
annual) income benefit for the life of a person or for a
specified period of time. The annuitant (insured) can
never outlive the income from the annuity. While the
basic purpose of life insurance is to provide an income
for a beneficiary at the death of the insured, the
annuity is intended to provide an income for the life of
the annuitant.
There are two basic types of
annuities, fixed annuities, which pay a fixed income
backed by fixed dollar investment such as secure bonds
and mortgages, and variable annuities, which vary in
payment according to the value of stock and bond
investments.
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FOR YOUR CONVENIENCE
Get direct quotes for individual and
family policies from some of our providers by clicking
on any of the links below:
If you need assistance
or would like additional info, please use the links to
the left.
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