Health Care Insurance FAQs

What is the basic difference between individual and group health insurance coverages?

An individual policy is purchased by you directly with the insurance company. With a group health insurance policy, the group is the master insured and the insurance company contracts with the group.
What’s the difference between primary and secondary coverages?

Primary coverage is provided through the plan of which they are a member or the plan under which the member has been a participant for the longest time period. Secondary coverage, usually as a result of being covered as a dependent under someone else’s health insurance plan, provides reimbursement for medical expenses after exhaustion of coverage available through the primary plan.
What services and items might be paid for under my health insurance?

Typically doctor visits, surgeon and surgery expenses, costs of hospitalization, and follow-up therapy are covered by health insurance. Some plans provide for psychiatric care, drug and alcohol rehabilitation programs, and prescription medicines.
What variables will affect my insurance premium?

Some of these variables include (but are not limited to) deductible, co-payments and co-insurance, lifetime maximums, annual or “out-of-pocket” limits, and coordination of benefits

While Medicare is broken down in to four different parts; A, B, C, and D, there are a number of plans for someone to choose from under Medicare. Medicare is health insurance provided by the government, not private insurance companies. Someone becomes eligible for Medicare if they are 65 years of age or older, under 65 and receiving disability payments, or if they have permanent kidney damage requiring dialysis. The most basic of plans is the Original Medicare Plan. This plan includes type A, hospital coverage, and type B, basic medical coverage.  An individual will pay a deductible each year, which must be met before the government starts to pay, and co-payments at the time of service. Part B is optional, and if used, the member is subject to a monthly premium as well.

Medicare part C is actually a plan in itself. These plans are called Medicare Advantage Plans. They work like HMO’s and PPO’s.  Such plans include parts A and B and cover extra services outside of the Original Plan, such as dental care, vision care and gym or health club memberships. With an Advantage plan, any medically-necessary service must be covered. Most Advantage Plans also include part D, which is prescription drug coverage. Members of part C are also insured against catastrophic costs over $5,000 and usually have a portion, or all, of their parts B and D premiums refunded.

Part D of Medicare is prescription drug coverage. Someone can have solely a prescription drug plan, of which there are thousands to choose from, based on the drugs needed, a member’s location, and preference of generic or brand-name drugs. A Prescription Drug Plan Finder can be used to find the best plan for an individual.

The rarest form of Medicare is the Medigap plan. It covers some of the holes not filled by the Original Plan, such as providing emergency care outside of the U.S., and in some cases, helping with prescription drug costs. These plans are set up through private insurance companies, which then share the costs with the government.

A mini guide on what you need to know about finding group health insurance.

- Don’t get confused between an agent and a broker, they are two completely different people. An agent represents an insurance company, while a broker represents the policyholder. An independent agent is unaffiliated with any particular insurer and represents a range of companies. Both agents and brokers can quote on your group health insurance plan.

- You may be able to fully deduct the premiums paid on your group health insurance plan. You may also reduce your payroll tax by offering health insurance coverage as part of a total compensation package.

- Group health insurance plans generally fall into one of two categories. You should become familiar with them.

*Indemnity (reimbursement) plans let your employees choose their own doctors and have their medical expenses paid totally, in part, or up to a certain amount per day for a certain number of days. These types of plans are rarely offered now because of their high cost.

*Managed care plans include health maintenance organizations (HMOs), preferred provider organizations (PPOs), and point of service (POS) plans. These all involve an arrangement between the insurer and a selected network of doctors, hospitals, and other healthcare providers.

- A good group health insurance policy contains several types of coverage.

*Hospital expense insurance pays room, board, and incidental services costs if an employee is hospitalized.

*Surgical expense insurance covers surgeons’ fees and related costs.

*Physicians’ expense insurance pays for visits to a doctor’s office or for a doctor’s hospital visits.

*Major medical insurance protects your employees against losses from catastrophic illness or injury.

- You can get a good group health insurance rate and still retain valuable coverage for your employees through a high-deductible plan.

Medicaid in Texas is designed for people of limited means to get the health treatments they need for themselves and their children.

To be considered for Medicaid in Texas, one must fill out an application. The application will be available in both English and Spanish. Not every application will be approved. It depends on the number of members of the family and the family’s poverty level as well as the health conditions of the people within the family. An individual making under the poverty level qualifies, but sometimes a family doesn’t, when one does the figures for family levels of poverty. Reports show that Texas is one of the leaders of children in poverty in the United States.

Texas Medicaid requires that a family has less than $2000 in assets. It is a stringent process to qualify for Medicaid in Texas, but if one does, then at least one knows that he/she can receive some semblance of health care.

Part B of Medicare covers many of the areas that are not covered by Medicare part A. Individuals are qualified to receive part B if they are receiving Social Security disability payments for 24 months, Social Security retirement payments, or if they are entitled to Medicare part A . When your Medicare card is sent, you have the option to deny Medicare B coverage. However, you can enroll in part B during the open enrollment period for no charge or at any other time, if eligible, and by paying a fee. Part B covers physicians’ services, outpatient visits, x-rays , medical equipment and similar services.

1. Physicians’ services;

2. Home Health Care;

3. Services and supplies, including drugs and biologicals which cannot be self-administered, furnished incidental to physicians’ services;

4. Diagnostic x-ray tests, diagnostic laboratory tests, and other diagnostic tests;

5. X-ray therapy, radium therapy and radioactive isotope therapy;

6. Surgical dressings, and splints, casts and other devices used for fractures and dislocations;

7. Durable medical equipment;

8. Prosthetic devices;

9. Braces, trusses, artificial limbs and eyes;

10. Ambulance services;

11. Some outpatient and ambulatory surgical services;

12. Some outpatient hospital services;

13. Some physical therapy services;

14. Some occupational therapy;

15. Some outpatient speech therapy;

16. Comprehensive outpatient rehabilitation facility services;

17. Rural health clinic services;

18. Institutional and home dialysis services, supplies and equipment;

19. Ambulatory surgical center services;

20. Antigens and blood clotting factors;

21. Qualified psychologist services;

22. Therapeutic shoes for patients with severe diabetic foot disease;

23. Influenza, Pneumococcal, and Hepatitis B vaccine;

24. Some mammography screening;

25. Some pap smear screening, breast exams, and pelvic exams;

26. Some other preventive services including colorectal cancer screening, Diabetes training tests, bone mass measurements, and prostate cancer screening.

Medicare B does not cover the following services:

1. Services which are not reasonable or necessary;

2. Custodial care;

3. Personal comfort items and services;

4. Care which does not meaningfully contribute to the treatment of illness, injury, or a malformed body member;

5. Prescription drugs which do not require administration by a physician;

6. Routine physical checkups;

7. Eyeglasses or contact lenses in most cases;

8. Eye examinations for the purpose of prescribing, fitting, or changing eyeglasses or contact lenses;

9. Hearing aids and examinations for hearing aids;

10. Immunizations except for influenza, pneumococcal and hepatitis B vaccine;

11. Cosmetic surgery;

12. Most dental services ;

13. Routine foot care

Medicare B covers 80% of medical fees, based on what Medicare considers a "reasonable charge" for a certain service. If there is a discrepancy between a doctor’s fee and the "reasonable charge" the patient is responsible for the difference. However, the provider is not legally allowed to charge more than 115% of the "reasonable charge". The biggest complaint about Medicare B is the out-of-pocket expenses. The monthly premium for part B is based on income and is between $96.40 and $238.40. There is also a $135 deductible, meaning that the patient must pay $135 for services before Medicare will start to cover its 80%.

Here are some facts and tips on individual health insurance to help educate you on the subject so you can make an informed decision next time you shop for insurance.

- Make sure the policy protects you from large medical costs.

- Make sure there is a “free look” clause. Most companies give you at least 10 days to lookover your policy after you receive it. If you decide it is not for you, you can return it and have your premium refunded.

- Beware of single disease insurance policies. There are some policies that offer protection for only one disease, such as cancer. If you have health insurance, your regular plan probably already provides all the coverage you need. Check to see what protection you have before buying any more insurance.

- Before purchasing any individual health plan, it is important to verify that the carrier and agent are licensed

- Individual coverage may be purchased as either an indemnity or managed care plan. Indemnity plans are sold exclusively by insurance companies, and will generally cover services from any licensed health provider as long as treatment is consistent with the terms of the policy.

- Typically, managed care plans are more affordable than indemnity plans, but indemnity plans provide members with the most flexibility in obtaining health services. The trade off is essentially choice versus cost.

- Sometimes individual health insurance consumers have the option to pay extra for coverage of additional services like maternity coverage. This extra coverage is referred to as an optional rider. These are usually not covered on the basic individual health insurance plan.

- If the insurance company is unable to obtain information necessary to accurately determine the risk of a particular applicant they will assume negatively.

- Once the company has determined your health status, you will be assigned a rate class by the company and put into a pool of other insured individuals with similar health status. Your premium will be the rate charged to that entire class of customers.

- In some states, you can receive credit against a pre-existing condition waiting period if you have had prior health insurance coverage within a specified number of days. The amount of the credit against the waiting period is generally proportional to the length of the prior coverage.

Medicaid and Medicare have similar benefits, but different target audiences and structures.

Medicaid targets those who are in desperate need for medical care. Medicaid is a social welfare program. Medicaid provides relief for pregnant mothers, people disabled, chronically disabled adults, mentally ill people and has slightly different rules based on one’s state. It’s generally for people in poor health due to poverty whether than age, even though a small group of seniors receive Medicaid, but those seniors tend to be ones struggling with high medicine costs and with little assets.

Medicare almost always is for those over 65. Medicare is a single-payer health care system and is controlled by the federal government. It ensures medical coverage for the older members of the population. The very first person to qualify for Medicare was President Harry Truman when President Lyndon B. Johnson signed Medicare into law. If one is a citizen of the United States for five years or more and meets the age criteria, one will be eligible for Medicare. Medicare covers both hospital insurance and medical insurance. If one is under 65 and gets Medicare, it’s because that person receives Social Security or Railroad Retirement Benefits for 24 months or are on dialysis or eligible for Social Security Disability insurance and suffer from Lou Gehrig’s disease.

Thank goodness these systems are in place to ensure Americans quality health care.

Medicare.gov is the official U.S. government site for people with Medicare. It is considered a “consumer beneficiary” website that provides information on Medicare, Medicare health plans, Medicare prescription drug plans, eligibility, providers in your area, and basically any and all information one could need when a member of Medicare. Users are allowed to sign up as members of the website and save and document the information that they come across and find useful. Every form one could need is available for download as are pages and pages of doctor, and other provider, information according to a specified location and area of specialization.

Medicare.gov is an invaluable website for Medicare and Medicaid members. The most impressive feature of the site is its multiple search tools. One can search to compare and contrast doctors, facilities, and services they are eligible for.  The search criteria can be very detailed and specific and the user will still be provided with a wealth of information. Perhaps the most helpful tool on the site is the long-term care planning tool. This tool allows users to search options for the present and the immediate, and not-so immediate, future. From there they can make a contigency plan if something were to happen where they were not able to take care of themselves anymore.

Our older generation, the “greatest generation” according to Tom Brokaw, are not as technologically savvy as the youngest generations. Navigating a simple website can be surprisingly difficult, as the technology is still foreign to them. A retired person, who was out of the workforce before computers were commonplace, might normally have a hard time taking advantage of this site. Medicare.gov provides clear, logical links, offers tutorials on search tools, such as the prescription drug plan finder, and makes most forms available for download as well as submission over the internet. The site makes available excellent information, which is not only easy to find, but also, easy to understand. Any and all members of Medicare and Medicaid have a remarkable tool in Medicare.gov. Necessary, important information is only a click away.