Health Insurance 411


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

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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
  • Health Insurance 411

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