![[email_address] Members will have their own, personalized health resource center on the web. Healthy Living offers interactive tools to help your employees assess, manage and improve their health. Sections include: Children’s Health News Men’s Health Women’s Health Mental Health Alternative Medicine Daily Health Tips Anthem Blue Cross 360º Health Resources Healthy Living provides timely, trusted and personalized information to engage members](https://image.slidesharecdn.com/stevepowerpointpresentation-124449825231-phpapp02/85/Health-Insurance-411-35-320.jpg)
Health Insurance 411
- 1. Your guide to all your health insurance needs Presented By:
- 2. Cost of Health Insurance Dramatically Rising New Technology / Equipment Rx costs Covering the Uninsured Hospital Costs Shift - Types of insurance & Cost Sharing by Employers
- 4. Styles of Health Insurance HMO : Health Maintenance Organization PPO : Participating Provider Organization HDHP with HSAs : High Deductible Health Plan that may be paired with the financial product, a Health Saving Account.
- 6. Definitions used in Health Insurance Copays: Deductible: Coinsurance: OOP (Out of Pocket Maximum): Life Time Maximum Dollar amount that offsets partially the cost of medical care Dollar amount to be paid for medical services before insurance coverage engages Percentage or cost sharing of medical expense after deductible is met. Maximum amount to be paid by enrollee before insurance covers expenses fully The maximum liability that the policy will cover
- 7. Definitions Continued… Rx 15/35/50/30% Generic Brand Name Non – Formulary Self injectibles The categories have been changing
- 8. Example of an HMO
- 9. Example of an PPO
- 10. Example of HSA Eligible
- 11. Health Savings Accounts Bank Account paired with H.D.H.P Employers and /or Employees can fund the account Account is owned by the employee or individual who is primary on the health insurance Tax Deductible Contribution – Tax Free Withdrawals – Eligible Medical Expenses
- 12. Other Styles Indemnity : Traditional format with no in or out of network contract Limited Benefit : Newer Major Medical that may cover only some hospitalization, ER visits, and limit OOP and/or lifetime maximums
- 14. Non Insurance Discount Programs Network Plans Promise – Can’t Be Turned Down Office Visit?? Rx Covered ??? What’s Left Out????
- 15. Definitions Continued… Preventative: Diagnostic: Annual, nationally listed care for children & adults, i.e., immunizations, mammograms, PSA Treatment or testing for existing conditions
- 16. Definitions Continued… Behavioral Health Mental Health, Substance Abuse, Alcohol Abuse Limited Benefits - inpatient 45 days / yr. outpatient 20 visits/ yr. detox – 3 days Substance Abuse – very limited benefits Parity - treat mental health at the same level as physical health - State Reg - Biologically Based Mental Illness – Parity Reality Check
- 17. Available Health Insurance Coverage Individual and Family Plans Short-Term Health Insurance- 30 days to 6 months Employer Sponsored Plans Medicare / Medicaid/ Cover Colorado/ CHP
- 18. Individual and Family Plans Eligibility based on health underwriting Lower Cost - due to a healthier population Paid by the individual Health Issues Riders Rate ups Decline
- 19. Short Term Health Insurance Immediate Coverage –PPO Major Med for Hospital & ER 30 days to 6 months Can be declined for pre-existing conditions Do not cover pre-existing conditions Good for the gap between becoming eligible at a new job, or recent university grads
- 20. Employer Sponsored Plans Small Group Plans Business Group of One 2-50 Employees Large Group Plans 51 + Employees (some carriers consider >100)
- 21. Employer Sponsored Plans Business Group of One (BGO) Guaranteed Issue State Mandated Plans Standard & Basic HMO & PPO plans Indemnity Plans Open Enrollment periods Proof of Business
- 22. Employer Sponsored Plans Small Group 2-50 employees Guaranteed Issue Proof of Business Rates Based Upon Plan Design, Age, SIC Code and Tobacco Usage State Mandated Coverages Basic plans – stripping out some of the preventative Table Rates or Composite Rates
- 23. Example Rate Table
- 24. Employer Sponsored Plans Large Group 51 + employees Not Guaranteed Issue Rates Based upon Health Experience, Age, and Plan Design SIC Code and Tobacco Usage Play a part in the rates. Larger Groups - rates are Negotiable Proof of Business
- 25. Employer Sponsored Plans Self Funded Plans share the risk with employers Employer Pays Claims up to individual & group limits TPA or Insurance Company Administers Claims Stop Loss Limits - Cap Liability Lower Initial Cost but Higher Risk
- 27. Enrollment Eligibility Qualifying Events Major Life Events, i.e., Birth, Adoption, Legal Guardianship, Marriage, Divorce, Death Loss of coverage through no choice of your own Open Enrollment New Hires - waiting period Pre existing conditions Fraud See Colorado Division of Insurance definitions MIB (Medical Information Bureau) Like a credit bureau, has records of your medical history, and can be checked annually for accuracy to control ID theft. Also IntelliScript checks for filled prescriptions.
- 28. HIPPA Health Insurance Portability and Accountability Act, Privacy Right to Convert COBRA/ State Continuation COBRA is federal law mandating the right to temporarily continue group health coverage for a period of time State Continuation is state law to fill in gaps left by COBRA for employee groups with less than 20 employees
- 29. COBRA/ State Continuation New Federal Regulation : Federal Government will subsidize 65% of Premium for up to 9 Months. If Business Fails - COBRA ends
- 30. New COBRA Regulations For involuntary loss of employment only Loss of employment from 9/1/08 to 12/31/09 If from 9/1/08 to present you have had employees eligible for COBRA must contact them with the new eligibility period (from 2/17/09 for 60 days forward) Starting 3/1/09 employees that elect this coverage will pay 35% of the premium. Starting 3/1/09 employers of these electees will pay 65% to be reimbursed on their payroll taxes.
- 31. End of COBRA or Continuation Conversion or CoverColorado The right to convert a group health insurance policy after completion of COBRA, being ineligible for individual health insurance due to significant pre-existing conditions. Premiums may be up to 2.5 times of normal CoverColorado is our state’s “uninsurable risk pool”, providing insurance for those who are declined individual health insurance coverage or who have certain listed conditions
- 33. Web Access
- 34. We’ve designed a broad spectrum of health services to meet the needs of your total member population. Anthem Blue Cross 360º Health Services Overview Health Resources Access health and wellness information. Health Extras Maximize opportunities for better health. Health Guidance Get help when in need of care. Health Management Receive ongoing management and help coordinating your care.
- 35. [email_address] Members will have their own, personalized health resource center on the web. Healthy Living offers interactive tools to help your employees assess, manage and improve their health. Sections include: Children’s Health News Men’s Health Women’s Health Mental Health Alternative Medicine Daily Health Tips Anthem Blue Cross 360º Health Resources Healthy Living provides timely, trusted and personalized information to engage members
- 36. Web Access Employers Real time access for HR to manage enrollments and terminations of employees, and billing
- 38. Medicare Part A - Hospitalization: entitled to premium-free enrollment if you or your spouse paid Medicare taxes Part B - Doctor and lab coverage: Income based premium from SS check or self paid Part D - Rx coverage
- 39. Medicare Continued… Medicare Advantage Medicare Supplements Sometimes referred to as Medicare Part C, a hybrid of Part A, B, and D that are assigned to the carriers Uses contracted doctors and hospitals only Useful outside of contract area only in emergencies Kaiser, Secure Horizons Also called Medigap plans, originally had 10 plan levels Need to purchase Medicare Part D coverage for RX needs Has in and out of network benefits, so it travels better for “snowbirds” AARP - United
- 40. Medicare Continued… Group Size determines whether Medicare is Primary or Secondary in paying claims Secondary coverage acts as Medicare “supplement” Medicare Eligible cannot contribute to funding HSAs Some disabilities before age 65 are Medicare eligible Carriers must annually report enrolled Medicare persons on group plans to be in compliance with new law. Employer groups will need to share SS# of people that are Medicare eligible.
- 42. Colorado Division of Insurance Consumer Protection is their mission Source of consumer information Performs market conduct and financial exams on insurance companies File consumer complaints online or call 303-894-7490
Editor's Notes
- #2: 20 yrs. I own Health agency SBA and a PEO - DeltaHR. Our Focus is health ins for business. I called this 411 as it is an informational discussion Health Ins has become a very fast changing business Primarily because of the dramatic Rise in Cost