Individual & Family
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FAQ

 

What is the status of the individual health insurance market today?

Probably the best way to review is to look at the attached slide show.  See below. .      

 

What are my options for individual health insurance coverage?

You may purchase coverage from a commercial insurance company under an individual or family plan. Depending on your income, you may qualify for government programs such as MediCal or under the new Exchange called Covered California. Note that if you wish to have an agent assist you there is no additional charge and you will benefit from our expertise.

 

 The Healthy Families program is being consolidated under MediCal. If you are over age 65 and covered by Medicare, you may want to purchase a Medicare Supplement or enroll in a Medicare Advantage plan. Be cautious that any Medicare Advantage plan actually has adequate provider access for you!



What options are available under commercial insurance plans for individuals and families?

There are four basic types of health plans: Indemnity, PPO, EPO and HMO plans.


Indemnity plans pay benefits to the insured. This could be a comprehensive plan or a limited scheduled plan.

Comprehensive plans usually reimburse the insured at a percentage of billed charges after a deductible has been met. The deductible is the amount the insured must pay first, before any expenses are reimbursed. Only "covered" expenses accrue toward the deductible. It's important to under stand the plan's exclusions when you purchase coverage.

PPO Plans provide an incentive to the insured to use a certain group of medical providers. The plan will pay the highest level of benefits when using the "preferred " providers. This usually benefits the individuals because they also benefit from the discounts that have been pre-negotiated with the providers.

For example: the billed charge for an x-ray is $60. The PPO plan's "negotiated rate" is $45. If the insured's has not met their deductible, the insured pays the $45. If the deductible has been met, then the insured pays their percentage of the $45. If the plan pays 80%, the insured would pay 20% of $45 or $9 instead of 20% of $60 or $12.

The greatest saving is on high dollar cost services. In many cases the PPO discounts are very large and save the insured thousands of dollars. (Anthem Blue Cross of California and Blue Shield of California)

 

EPO Plans:  Means EXCLUSIVE Provider.  Should you receive care from on non-network provider there is NO benefit.  It is important to review networks before choosing such a plan. You may self-refer in these plans.

HMO Plans: These plans are the most restrictive. Typically, the individual must use the plan's providers or receive NO benefits. Further, the health plan will often require that care be directed through the Primary Care Physician (PCP) of the individual. If an individual is comfortable with the health plan's rules, this will often result in the least out of pocket cost and the richest benefits for the insured.




Do I have to take a physical to apply for health insurance?

  

Starting in 2014 all plans are "guaranteed issue". So not only do you not have to take a physical, you may not be turned down and your pre-existing conditions are covered once you are approved.

If you do not have current coverage, we recommend that you consider temporary insurance for coverage until 1/1/2014. If you can answer “no” to a few questions, you will be covered immediately. This coverage is also appropriate for persons between jobs or students who have recently graduated.

 

Starting in 2014 all plans will be guaranteed issue and which means not subject to underwriting.  You may be eligible for a subsidized premium based on income through the Exchange.  Coverage can be purchased through any agent authorized to represent the Exchange 




What kind of coverage should I buy?

We recommend that you buy the highest deductible you can afford. Note that plans now have unlimited lifetime maximums. Also, look at the "out of pocket maximum". This is your "worst case" share of the expenses in the event of a catastrophic illness.
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What is an HSA?

A Health Savings account is available to all persons covered by a Qualified High Deductible Health Plan (HDHP). This allows them to set aside money on a tax favored basis to pay qualified medical expenses, while still maintaining a high deductible health plan to protect against catastrophic loss. The best part is if you don't use the money, it continues to accumulate and can supplement your other retirement plans. This way the money is in your pocket, not the insurance company's. Check out www.hsabank.com for more information and see us for your health plan! We can refer you to a local bank to establish your account.

 

  

   
  

 


     
   
What is MediCal?

MediCal is the federally subsidized health plan for low- income people. In some states it is called MedicAid. Applications can be obtained by appointment through the County Social Services Department.

 

What is MAGI MediCal?

 

The Affordable Care Act expands MediCal to a higher income level and there is no asset test for these individuals who have income up to 138% of the Federal Poverty Level. Children are eligible up to 200% of Federal Poverty Level (FPL)

What is a Medicare Supplement?

These are plans designed to pay the share of expenses that Medicare does not pay. The standard plans are label A through to N. All standardized plans provide the same benefits, which makes it easier for consumers to compare. Plan A provides the lowest benefits and Plan F provides the highest. There is an open enrollment period every year in your birthday month to make a lateral change.  These plans are "guaranteed issue" to those turning age 65 and becoming eligible for Medicare benefits.

It is important to evaluate coverage. For example, If the out of pocket maximum exposure on a High Deductible Plan F is $2110, but you are paying an additional premium of $100 monthly or $1200 per year for a Standard Plan F, then you really are buying about $910 of insurance.  

 

What is Medicare Part D?

This is the prescription drug benefit availabe to Medicare eligible individuals.  The plan is designed and partially funded by the government, but delivered by private insurance companies.  There are many plans available in each zip code area.  The best plan for you will likely depend on your medications list.  We are all one doctor visit away for a new Rx, but it is my opinion that you are best served to evaluate the plan based on your current list.  You can do so at www.medicare.gov.  We are happy to assist our clients with this exercise.


 

 

 

Links:

    * HSA: http://www.hsabank.com/hsainfo/staticcontent.aspx?contentID=576
    * BLUE SHIELD AND BLUE CROSS Medicare and Medicaid: https://www.cms.hhs.gov/
    * Healthy Families: http://healthyfamilies.ca.gov/

 

Medicare:  www.medicare.gov

 

Covered California: http://coveredca.com   

 

Downloads:

 

SeminarIFP11413.pdf