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?
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.
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;
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;
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%.
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.
Medicare part D is an important part of the Medicare Prescription Drug, Improvement, and Modernization Act enacted in 2003. However, it did not begin to take effect until January 1, 2006. The plan is administered by The Centers for Medicare and Medicaid Services (CMS) . Medicare part D provides insurance coverage on prescription drugs, but is not part of the original Medicare program. Private insurance carriers actually administer the Prescription Drug Plan (PDP) and they are reimbursed by CMS.
There are two private plans under which someone can receive prescription drug coverage; through a Prescription Drug Plan that covers drugs only or through a Medicare Advantage (MA) plan. A MA plan includes both medical services, parts A and B, and prescription drugs. There are about 40 to 50 Medicare part D plans, on average, in each state or CMS region. As of the start of 2008 there are over 1,800 part D plans available. These different plans allow the covered to choose the drugs to be covered, the types of drugs, and therefore the copay they will be responsible for. Average monthly premiums for the standard plans are around $30, but can range from $8-$135. Those enrolled can use a Prescription Drug Plan Finder to figure out the best plan for them based on price, drugs and location. These plans are the best for individuals who regularly take prescription drugs.
The MMA also established a standard benefit plan available to all part D participants. This plan includes a $295 deductible. Once the deductible has been reached Medicare will pay for 75% of prescription drug costs up to a $2,405 initial coverage limit. After this amount is reached, the patient is in what is called "The Donut Hole " or coverage gap. They must now pay the full price of their prescription drugs until total yearly spending has reached $4,350. This means that they will be responsible for $1,945 of prescription coverage. Once they have passed the $4,350 limit, catastrophic coverage is reached, which provides generic medications for $2.25 and brand-name for $5.65, or 5% of total cost, whichever is greater. The standard plan is more suited for infrequent prescription drug users or those who are not taking prescription drugs currently, as a contingency plan.
