Got Insurance?

*Please check with your state to see how they are implementing the federal legislation

The Federal health reform legislation expanded access to health insurance for children with pre-existing medical conditions by requiring insurance companies to offer group or individual health insurance coverage to children under the age of 19, regardless of their medical history. In California, Assembly Bill (AB) 2244, which was signed into law September 2010, established an open enrollment period to apply for these “child-only” health insurance policies, which runs for 60 days, beginning on January 1, 2011.

Following the 2011 initial open enrollment period in California (January 1 through March 1) a child’s birth month will become the child’s annual open enrollment period. If the newborn child is not enrolled in health insurance during the month that they’re born, they’ll have an additional 63 days (late enrollment period) to enroll in health coverage. If the child does not enroll in health coverage within the allotted time, the child’s application for private health insurance may be assessed a 20 percent surcharge for a period not greater than 12 months. The child may be eligible to enroll as a “Late enrollee” if a qualifying event exists (see below). During which time they may not be subject to the increase in premium.

Qualifying events to be considered a late enrollee outside of the open enrollment period:

• The child lost dependent coverage due to termination or change in employment status.
• An employer who provided the child’s coverage, either directly or through a parent or guardian, stopped contributing financially toward the cost of the employee or dependent’s health coverage.
• The person through whom the child was covered as a dependent dies.
• The person through whom the child was covered as a dependent goes though a legal separation or divorce.
• The child loses coverage under the Healthy Families Program, the Access for Infants and Mothers Program, or the Medi-Cal program.
• The child is adopted.
• The child becomes a resident of California during a month that was not the child’s birth month.
• The child is mandated to be covered pursuant to a valid state or federal court order.

It’s important to understand that these enrollment guidelines for CA are in place to prevent consumers from waiting until their child is sick to sign them up for insurance. It maintains a balance between the importance of allowing all children to have access to private health coverage and keeping private non-group health coverage affordable for residents of the state.

Jolene Bibian, RP

Registered Paraplanner^SM

Ca Ins Lic # 0E33032

Leon Rousso & Associates

jolene@leonrousso.com

As with any new language, it all seems so complicated and confusing at first. Many times the more you try to understand, the more confused you get. This is especially true with the “Health Insurance Language”. One way we tend to deal with complicated issues is to stick to what we know. We all know “Price”, right? So we look at how much it will cost us each month and try to go with something cheap.  Well, that will quickly backfire when it comes to Health Insurance. The minute you really need it, you will be thankful your parents taught you “You get what you pay for”. The more you understand the basic terminology of how insurance works, you will be able to ask the right questions when shopping for the a plan that fits your needs. Below are some basic terms to help you build a foundation of understanding.

• Premium: The monthly fee you pay to the insurance carrier for your policy
• Deductible: The annual amount you pay before the insurance carrier will pay their portion of the bill
• Contracted amount (PPO): The amount an In Network provider is contracted to charge for services rendered
• Co-pay: A stated amount you as the member will pay for certain services that are not subject to the deductible such as “Dr. Office Co-Pay”
• Co-insurance: The percentage you pay for services rendered after you have met your deductible.
• Out-of-pocket maximum: The total annual maximum you will pay for covered services.

Premium:

This is the monthly amount you will pay to the insurance carrier. Many factors such as the Deductible, Co-insurance and Out-of-pocket max will determine how much your premium will be.  In general, the lower your out of pocket expenses are the higher your monthly premium will be. It’s important to look at more than just monthly premium cost when shopping for insurance. This is why speaking to your agent/broker about your medical and financial needs is extremely valuable when comparing options.

Deductible:

Your deductible is the amount you will pay before the insurance carrier will pay their portion for covered services. It’s important to know prior to meeting your deductible, you will pay the entire contracted amount. For example: Your plan has a $500 deductible and you go in for a sore throat. Your PPO provider examines your symptoms and performs a few tests, including a throat culture. The contracted amount is $500 for services rendered. You will be responsible for $500 and that amount will get applied to the deductible. Your provider calls to tell you they need a follow up test to make sure the infection found from your throat culture is gone. The contracted amount for that service totals $200. Since you met your annual deductible at last visit you will only pay your Co-insurance percentage of the $200.

Contracted amount:

There are a variety of ways the various insurance carriers refer to the contracted amount or discounted rate. However, with a Preferred Provider Organization (PPO) you will have a network of providers that are contracted with the insurance carrier. When you stay in this network of contracted providers, you will be protected by this contract. One way you will be protected is by how much the provider can charge you for covered services. Since you will be required to pay 100% of the contracted amount prior to meeting the deductible, it’s good to know that you will still be getting a discount on the entire amount the provider actually charges. Referring to your sore throat scenario, the total billed for the initial service rendered was $800. However, your doctor was in the PPO network. So the carrier’s contracted amount was $500. The difference of $300 gets written off and the provider cannot balance bill you for that amount according to the contract.

Co-pay:

Co-pays are typically fixed dollar amounts that you must pay directly to the provider at the time services are rendered. Co-pay amounts generally are not subject to your annual deductible, therefore do not go towards satisfying your annual deductible or Out-of-pocket max.  For example: in the sore throat scenario above, your doctor’s office most likely required you pay the office Co-pay upfront which didn’t include the throat culture or follow up test. You will also pay a Co-pay to the pharmacy when picking up prescriptions.

Co-insurance:

Co-insurance is the percentage you and the insurance carrier share in paying for services rendered once your deductible is met. Plans are typically 20/80, 30/70, 50/50 etc.  This applies to services rendered above and beyond what is included in a basic office visit Co-pay for hospitalization, surgeries, procedures and emergency room services. In using the same sore throat scenario above, if your plan’s Co-insurance is 30%, you will pay $60 of the $200 contracted amount and the insurance carrier will pay $140 (70%).

Out-of-pocket maximum:

In my opinion and experience, this is why you pay for insurance. Your Out-of-pocket maximum is your maximum annual financial loss if you are seriously injured or become ill. Once you meet your annual deductible you will pay your co-insurance percentage. Once your co-insurance percentage equals your Out-of-pocket maximum, the carrier will then pays 100% of the bills for the remainder of that calendar year. Going back to the sore throat scenario, your $60 (30%) goes towards your Out-of-pocket maximum. Hospitalization and surgeries can become a significant financial liability. The majority of us will find it near impossible to pay for a serious procedure that can easily be $100,000+ . However, having an Out-of-pocket maximum of $5,000 is much more manageable.

These basics should help you understand the mechanics of how Health Insurance works. Although, there are many other factors to consider when shopping for a policy. Feel free contact me at the email below if  I can be of assistance to you and your family or business.

Jolene Bibian, RP

Registered Paraplanner^SM

Ca Ins Lic # 0E33032

Leon Rousso & Associates

jolene@leonrousso.com

While the common term is “Health Insurance”…it is really “Sickness” Insurance”.  If you rarely see a doctor, except for an annual preventive exam, you typically end up paying most of the bill. This leaves many healthy individuals in an uproar about paying their premiums.  If “nothing is covered”, in their eyes, because they are never sick, then why even have insurance, particularly if it’s a PPO.  (Preferred Provider Organization).

Few understand the importance of insurance until it is too late. Co-pays and other out-of-pocket costs to help prevent health problems were a stumbling block for many people. For example, 12% of children have not had a doctor’s visit within the last year for their annual checkup. And of those children who have, only half have received recommended care.

Many lawmakers in Congress began to understand that if people had preventive care covered many would be more likely to stay up on their health and insurance, rather than waiting until they became ill and incurred expensive hospital bills. It’s a simple concept that took some time to enact.

Under the new Health Reform legislation, if you enroll(ed) in a new health plan on or after Sept. 23, 2010, the plan must provide age and gender recommended preventive care services without cost-sharing , such as co-pays, co-insurance  or deductibles.

The new regulations represent a fundamental shift in how health care is addressed. Over time, between today and 2013, the new preventive care provisions will help an estimated 88 million Americans get preventive care, including those in both group and individual plans, according to government estimates. Under many large employer plans, these services have been covered for some time

Q: Do all health plans have to provide free preventive care?

A: No. Insurance plans that were already in place when health reform became law on March 23, 2010, are considered grandfathered and won’t be required to comply with a number of provisions of the new law.

However, the expectation is that most health plans will lose their grandfathered status due to significant changes in their benefit design by 2014 and be required to comply with all aspects of the new law.

Q: Can we count on free preventive care, or is everything in limbo?

A: Ever since the Affordable Care Act was passed in March 2010, there has been much talk about repealing the law — and in January 2011, the House of Representatives voted to repeal the Affordable Care Act. That has many Americans confused, believing that the health care reform law was overturned and that access to free preventive care, among other benefits, has been lost.

Nothing could be further from the truth. The law is still in place, because the Senate was not successful in their bid for repeal.

While lawmakers can hold up money for aspects of the law that have yet to be implemented, repealing the entire law or even specific consumer protections, such as preventive care, are not likely.

Q: Are there any situations in which I might be charged for a wellness (preventive) visit?

A: Yes. It’s important that you understand your specific benefit plan and the rules you must follow in order to have your care paid for.

In addition, you must see your doctor for the specific purpose of ‘preventive care’ in order to have the visit paid for in full. If you require a screening or blood test during your Drs. visit due to medical reasons other than prevention, you will likely have to share in some of the cost.

Some Important Details

• This preventive services provision applies to people enrolled in either group or individual health insurance policies created after March 23, 2010. If you are in a health plan effective after March 23, 2010, this provision will apply as soon as your plan begins its first new “plan year” or “policy year” on or after September 23, 2010.
• If your plan is “grandfathered,” these benefits may not be available to you.
• If your health plan is a PPO that requires you to use network providers, be aware that it is not obligated to provide these preventive services for out of network providers. Your health plan may allow you to receive these services from an out-of-network provider, but may charge you a fee.
• Your doctor may provide a preventive service, such as a cholesterol screening test, as part of an office visit. Be aware that your plan may require you to pay some costs of the office visit, if the preventive service is not the primary purpose of the visit, or if your doctor bills you for the preventive services separately from the office visit.
• If you have questions about whether these new provisions apply to your plan, contact your insurer or plan administrator.  If you still have questions, contact your State insurance department.
• To know which covered preventive services are right for you—based on your age, gender, and health status—ask your health care provider.

I encourage you to be proactive about your health care. Ask questions when you’re in the doctor’s office. Read your policy E.O.C (Explanation of Coverage). The more you know and are aware, the less likely you will be left in the dark.

Helpful links:

Healthy Men

Healthy Women

Jolene Bibian, RP

Registered Paraplanner^SM

Ca Ins Lic # 0E33032

Leon Rousso & Associates

jolene@leonrousso.com

With so many new regulations, mandates and changes to an already complicated necessity such as Health Insurance, its no wonder many of us are left asking for translation.

Unfortunately, or fortunately depending on how you look at it, “Health Insurance” will not show up in the high school curriculum anytime soon.

Have no fear, my friends. We have done all the dirty work for you. Let us guide you to “Health Insurance Enlightenment”!

Yes, I understand it isn’t the most exciting topic. But just think how your friends and colleagues will look up to you now that you know things they dont.

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