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Health Insurance 411

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Provides general information for all your health insurance needs in Colorado.

Provides general information for all your health insurance needs in Colorado.

Published in: Economy & Finance, Business

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  • 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
  • Transcript

    • 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
    • 3.
    • 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.
    • 5.  
    • 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
    • 13.  
    • 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
    • 26.  
    • 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
    • 32.  
    • 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
    • 37.  
    • 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.
    • 41.  
    • 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
    • 43.