Individuals under Age 21

EPSDT is Medicaid’s comprehensive child health program. The programs’ focus is on prevention, early diagnosis and treatment of medical conditions. EPSDT is a mandatory service required to be provided under a state’s Medicaid program.

Dental services must be provided at intervals that meet reasonable standards of dental practice, as determined by the state after consultation with recognized dental organizations involved in child health, and at such other intervals, as indicated by medical necessity, to determine the existence of a suspected illness or condition. Services must include at a minimum, relief of pain and infections, restoration of teeth and maintenance of dental health. Dental services may not be limited to emergency services for EPSDT recipients.

Oral screening may be part of a physical exam, but does not substitute for a dental examination performed by a dentist as a result of a direct referral to a dentist. A direct dental referral is required for every child in accordance with the periodicity schedule set by the state. The Centers for Medicare & Medicaid Services does not further define what specific dental services must be provided, however, EPSDT requires that all services coverable under the Medicaid program must be provided to EPSDT recipients if determined to be medically necessary. Under the Medicaid program, the state determines medical necessity.

If a condition requiring treatment is discovered during a screening, the state must provide the necessary services to treat that condition, whether or not such services are included in the state’s Medicaid plan.

Individual age 21 and older

States may elect to provide dental services to their adult Medicaid-eligible population or elect not to provide dental services at all as part of its Medicaid program. While most states provide at least emergency dental services for adults, less than half of the states provide comprehensive dental care. There are no minimum requirements for adult dental coverage.

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HSAs from a Few of Our Carriers

Aetna HSA

These days, you’re watching every health care dollar. And we can help you see that they don’t get lost. An HSA is a tax-advantaged savings account that lets you pay for current health care expenses. Or, you can save for future expenses. To be eligible for an HSA, you must be covered by a consumer directed health plan. And you must not be eligible for coverage under any other health plan. Here are some ways to make the most of your HSA:

• Tax Advantages – With payroll deduction, you can put money into your account before taxes. This may lower your taxable income.
• Carry-Over – HSA balances carry over from one year to the next. That’s true even if you change jobs or health plans. Once you set up an HSA, it’s all yours!
• You can use money from an HSA to pay for certain expenses (defined by the IRS). Get a list of these expenses from your health insurance broker East Coast Health Insurance

 Humana One HSA

The HumanaOne HSA-Qualified High Deductible Health Plan (HDHP) may be the right fit for individuals who want coverage in case of a serious illness or injury. With the HDHP, members have the comfort of knowing they’re covered.

Members can combine their HDHP with a Health Savings Account (HSA) to save money for health expenses. Contributions to an HSA are tax-free, grow tax-deferred, and earn interest.

Cigna HSA

A Cigna Health Savings Account (HSA) gives more: More control over health care decisions. More information and assistance to help make healthy choices. More options and more services.

In addition to health plan coverage, a Cigna HSA offers:

• A tax-deferred savings account to help pay for covered health care expenses.*
• Control over how health care dollars are spent.
• Freedom to choose doctors.
• Convenient, online information and tools to help decide which doctors and services are desired;  Programs and services to help you stay well.
• Financial stability through JP Morgan Chase, the administrator of the savings account.

* Several states have not enacted legislation to allow pre-tax treatment of HSA contributions and/or earnings. You should work with your tax advisor to ensure that you are aware of any changes that may occur in these states. For your convenience, we have identified the following states as having these tax issues: Alabama, California, New Hampshire, New Jersey and Wisconsin.

United Health One HSA

Health Savings Account plans from UnitedHealthOne combine lower-cost, high-deductible health insurance with a tax-advantage health savings account.Do you want more control over how your health care dollars are spent? Health Savings Account (HSAs) plans can help you take control of your health, your medical decisions, and your medical spending. An HSA can increase your health insurance buying power for several reasons.

These plans typically lower your health insurance premium, while still providing quality coverage. You can also gain more control of your health care dollars, and pay your out-of-pocket health care expenses with tax-advantaged savings. Your HSA savings are tax free to spend and help pay your health insurance deductible or for qualified medical expenses including prescriptions, vision, or dental care. HSA plans provide one simple, calendar-year deductible per family.

Blue Cross and Blue Shield HSA

Health savings accounts (HSA) allow members to save money into tax-advantaged accounts. Qualified contributions made to HSAs are tax-deductible, and funds withdrawn to pay for qualified medical expenses are tax-free. More information about qualifying expenses and the HSA regulation, Section 213(d) of the IRS Tax Code is available on the IRS website.

Like other QHDHPs, the various Blue Cross and Blue Shield companies offer plans with high deductibles that you can connect to a portable savings account. As each company is very different, their HSA plans will vary depending on the company and state where you purchase coverage. Anthem plans offer Lumenos HSA products in their respective states, and other independent BCBS plans provide their own rendition of the HSA option in every state of operation. To find out which BCBS HSA plans are offered near you, get a quote.

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HRA vs. Traditional Group Health Insurance Plans

Instead of having a group health insurance plan, some employers have opted to take part in an HRA, which gives tax-free money to employees for the purpose of purchasing their own individual health plans.  This helps not only to save money for the employer, but also allows individuals within the company to more accurately address their own unique health situations and chose coverage that provides them with the best options, instead of just going with whatever the company is going to provide.

Health care is a great thing, but having freedom to chose you own path when selecting health care is even better.  What is to say that one plan is going to be the best for everyone within an organization?  Employers can save themselves a lot of money in the long run, and also allow for their employees to get the best healthcare that they personally want too!

Other benefits for employers who switch to HRA’s

• Companies that provide group health insurance for their employees spend a lot of valuable time and resources annually to do so.  By switching to a defined contribution healthcare system you can more adequately address other company specific goals and issues!  Basically this is like freeing up a whole department to concentrate on other company prerogatives.
• A lot of companies are actually losing money these in providing group health insurance.  The cost of health benefits times the number of employees is, in most cases a situation that could be best rendered by allowing employees to be in charge of their own health insurance situations.
• Without the burden of having in house help coordinate health insurance benefits for employees, they are free to work on other company specific goals, services, and products.  HRA’s will continue to change the landscape for companies who would like to provide the best and most flexible health care for employees, while maximizing productivity and saving money all at the same time.

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…And when was the last time you met a college student concerned about health insurance?

Yes, it’s been a long time.  So, couple that fact with the unfortunate truth that most colleges have awful health insurance programs, and actually sell these policies to students as a health insurance broker would, even receiving the insurance commission in the case of some colleges.

What is the problem with this?  Because, these are limited benefit health insurance plans.  There are caps on benefits for certain injuries or illness and cannot be counted for catastrophic events.  Or, you have the other extreme, which is when the policies are only for catastrophic events and not for anything else.  So, again, in this case if your child were to develop a chronic condition that left them incapacitated or needing constant treatments these policies would exhaust quickly.

The Affordable Care Act also eliminated much of the need for student insurance by extending the deadline for dependent coverage to age 26. But, once you have a chronic illness or injury you can forget about ever (yes, ever) obtaining an individual health insurance policy.

That is the sad truth, that we live in a country that will let its medical profession turn away our sick in lieu of money.

That is why it is so important to obtain a PERMANENT Health Insurance policy for your college student throughout their college experience.  The alternative is scary.

The best part of this though, is that these plans are cheap!  18 year old males are one of the cheapest demographics in health insurance.  18 year old females on the other hand can be a little pricier, but Aetna, for instance, offers a terrific health insurance policy for young people male or female that is under $100 per month.  (This varies according to state.)

Now the actual post, because most U.S. colleges and universities including most state schools require students to have health insurance as a condition of enrollment, a student can provide their own private health insurance through their parent’s existing coverage or some schools will offer insurance through one specific carrier. Several state schools offer health insurance however our agents have typically seen these prices to be higher then the private individual insurance East Coast insurance can offer. Students and their parents are frequently motivated to find alternative coverage that may offer better protection at a lower price.

It is possible for most healthy students to find lower price protection with stronger catastrophic coverage with a wider range of providers on a national basis using the plans listed on a state-by-state basis at ECHealthInsurance.com. Since each student’s situation is different and sometimes even schools have different requirements, it pays to take a few minutes to speak with an agent an East Coast Health Insurance broker.

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Many times, a business owner will be unable to qualify for health insurance and if he or she is just starting a new company and has a few assets this person might not be able to get approved for individual health insurance. If I had my choice, I suppose I would prefer a high risk pool to a one man group, as risk pools are often underwritten by states.

In any case, this our state by state guide for one man groups.  If your state is not here, then you should check either our risk pool page, or visit your state’s health insurance home page to see what plans are offered in your state for high risk health situations.

Alaska

If you are self-employed with no other workers, you are not eligible to buy a group health plan on your own (though you may be able to join another group health plan through a family member). Therefore, the laws that protect employers’ access to group health plans do not apply to you. Your access to health insurance is protected by the laws that apply to individuals.

If you are self-employed and buy your own health insurance, you are eligible to deduct 100% of the cost of your premium from your federal income tax.

ACHIA. Alaska Comprehensive Health Insurance Association, the state-run insurance program for HIPAA eligible persons and for people with high health risks (called a high risk pool).

Alternative Trade Adjustment Assistance (ATAA). ATAA is a benefit for workers at least 50 years old who have obtained different, full-time employment within 26 weeks of the termination of adversely-affected employment. These workers may receive 50% of the wage differential (up to $10,000) during their 2 year eligibility period. To be eligible for the ATAA program, workers may not earn more than $50,000 per year in their new employment. Also, the firm where the workers worked must meet certain eligibility criteria.

Arizona

Usually, if you are self-employed with no other workers, you are not eligible to buy a group health plan on your own outside of the Healthcare Group of Arizona (HCG).  Therefore, the laws that protect employers’ access to group health plans do not apply to you. Your access to health insurance is protected by the laws that apply to individuals.

If you are self-employed, your only guaranteed access to health insurance coverage is through the HCG plan (see below).  If you are self-employed and buy your own health insurance, you are eligible to deduct 100% of the cost of your premium from your federal income tax.

The Healthcare Group of Arizona (HCG) is a state-run program that provides insurance to individuals who work for participating small employers.

· You also must meet minimum participation requirements.

· You cannot have offered health insurance coverage in the past 6 months.

California

If you are self-employed with no other workers, you are not eligible to buy a small employer group health plan on your own. Therefore, the laws that protect employers’ access to group health plans do not apply to you. Your access to health coverage is protected by the laws that apply to individuals.

If you are self-employed and buy your own health insurance, you are eligible to deduct 100% of your premium from your federal income tax.

Major Risk Medical Insurance Program (MRMIP). The state-run program that provides health coverage for people with high health risks (called a high risk pool).

Colorado

If you are self-employed with no other workers, you may be eligible to buy small group health plan coverage as a self-employed business group of one. To qualify, you must work in your business at least 24 hours per week on a regular basis. In addition, your business must have generated taxable income or you must have derived a substantial part of your income from the business. Substantial income is defined as an amount sufficient to pay your health insurance premium.

• If you qualify as a self- employed business group of one, small group health insurers must offer you the choice of a standard or basic health plan on a guaranteed issue basis during open enrollment periods. You cannot be turned down because of your health status. You may be able to buy other, non-standardized policies insurers sell to other small employers, as well; however, insurers can turn you down for these non-standardized policies because of your health status.

• You are only eligible to buy coverage as a self-employed business group of one during annual open enrollment periods. Your annual open enrollment period is the 31-day period following your birthday. Self-employed business groups of one are also entitled to coverage within 31 days of the following events: exhaustion of COBRA or state continuation coverage; the date you first meet the definition of a business group of one; or involuntary termination of other health insurance coverage. At all other times, your access to health insurance is protected by the laws that apply to individuals.

If you are self-employed and buy your own health insurance, you are eligible to deduct 100% of the cost of your premium from your federal income tax.

Connecticut

If you are self-employed with no other workers, you are eligible to buy the Basic Small Employer Health Plan. For more information about the Basic Employer Health Plan, contact the Connecticut Insurance Department, Life and Health Division at (860) 297-3800.

Insurance companies are allowed to require proof that you are self-employed or a business group of one.

If you are self-employed and buy your own health insurance, you may be eligible to deduct 100% of the cost of your premium from your federal income tax.

Delaware

If you are self-employed with no other workers, you are eligible to buy a group health plan on your own. You are guaranteed access to all health insurance sold to small employers.

If you are self-employed and buy your own health coverage, you are eligible to deduct 100% of the cost of your premium from your federal income tax.

Washington DC

If you are self-employed with no other workers, you are not eligible to buy a group health plan on your own (though you may be able to join another group health plan through a family member). Therefore, the laws that protect employers’ access to group health plans do not apply to you. Your access to health insurance is protected by the laws that apply to individuals (see Chapter 3).

• If you are self-employed and buy your own health insurance, you may be eligible to deduct 100% of the cost of your premium from your federal income tax.

Florida

If you are self-employed with no other workers, you are considered to be a group of one. Insurers are required to accept your application for a standard health plan, a basic health plan and a high deductible plan in August of each year to make coverage effective on October 1, of that year. They can refuse to sell you other plans, however. Further, the rules for pre-existing condition exclusion periods are somewhat different.

For groups of one, pregnancy can be counted as a preexisting condition.

If you are a group of one and you have had no prior coverage, the group health plan can exclude coverage for your preexisting condition for up to 2 years. The plan can count as preexisting any condition for which you received, or – in your insurer’s judgment, for which you should have sought – a diagnosis, treatment or medical advice in the 2 years prior to enrolling in the plan. This is called the prudent person standard. If you had prior coverage, you will receive credit toward your preexisting condition exclusion period for any time you satisfied under your prior coverage provided there was no break in coverage greater than 63 days.

In order to show that you qualify as a self-employed person or a business group of one, insurance companies are allowed to require that you provide them with your tax forms.

If you are self-employed and buy your own health insurance, you may be eligible to deduct 100 % of the cost of your premium from your federal income tax.

Georgia

If you are self-employed with no other workers, insurers may, but are not required to, treat you similarly to other small employers. While insurers can refuse to sell you the packages they make available to other small employers, they may choose to offer you a group health plan. If you are offered a small group health plan that is offered to other small groups, the limits on group health plan premiums will apply to your plan. If you are not offered a group plan, your access to health insurance is protected by the laws for individuals.

If you are self-employed and buy your own health insurance, you are eligible to deduct 100% of the cost of your premium from your federal income tax.

Hawaii

If you are an unincorporated sole proprietor with no other workers you cannot buy a group health plan. However, you may be able to join a group health plan through a family member or a professional association that sells group health coverage to other small employers or self-employed persons. If not, you can seek coverage in the individual market. (See Chapter 3.)

If you are a sole proprietor with no other workers and you incorporate your business, becoming the sole employee of that corporation, the laws that protect workers access to group health insurance also apply to you. (See Chapter 2) Provided that you work at least 20 hours per week for 4 consecutive weeks and you earn a monthly salary of at least 86.67 times the minimum hourly wage, your corporation, as your employer, is required to offer health coverage to you. Health insurance companies must sell your corporation any small group health plan they sell to other small employers. To find out more information about how to incorporate your business contact the State of Hawaii Department of Labor and Industrial Relations at 1-808-586-8842 or visit them on the web at http://hawaii.gov/labor/.

If you are self-employed and buy your own health insurance, you are eligible to deduct 100% percentage of the cost of your premium from your federal income tax.

Idaho

If you are self-employed with no other workers, you are not eligible to buy a group health plan on your own (though you may be able to join a group health plan through a family member). Therefore, the laws that protect employers’ access to group health plans do not apply to you. Your access to health insurance is protected by the laws that apply to individuals (see Chapter 3).

If you are self-employed and buy your own health insurance, you are eligible to deduct 100% of the cost of your premium from your federal income tax.

Idaho residents are guaranteed the right to buy Individual High Risk Reinsurance Pool (HRP) plans under certain circumstances. You may be able to buy a HRP plan if an Idaho insurer turns you down due to health status or claims experience or offers to sell you coverage at a premium higher than that charged for HRP plans. You are also guaranteed the right to buy this coverage if you are HIPAA eligible or eligible for the Federal Heath Coverage Tax Credit (HCTC). This is called guaranteed issue (see page 18).

Maine

If you are self-employed with no other workers, you may be eligible to buy a group health plan on your own (or you may be able to join another group health plan through a family member). However, insurance companies that sell both individual and group coverage can choose to offer you an individual health insurance policy only. If you cannot find a carrier that sells group coverage to sole proprietors, you can buy an individual health insurance policy and be protected by the laws that apply to individuals.

If you are self-employed and buy your own health insurance, you are eligible to deduct 100% of the cost of your premium from your federal income tax   If you own a small business with 50 or fewer employees, you may be able to purchase health insurance coverage for yourself and your employees through the DirigoChoice.

Alabama

If you are self-employed with no other workers, you are not eligible to buy a group health insurance policy on your own (though you may be able to join another group health plan through a family member). Therefore, the laws that protect employers’ access to group health plans do not apply to you. Your access to health insurance is protected by the laws that apply to individuals. (See Chapter 3.)

If you are self-employed and buy your own health insurance, you are eligible to deduct 100% of the cost of your premium from your federal income tax.

Did not find a high risk pool plan particular to Alabama.

Arkansas

If you are self-employed with no other workers, you are not eligible to buy a group health plan on your own (though you may be able to join another group health plan through a family member). Therefore, the laws that protect employers’ access to group health plans do not apply to you. Your access to health insurance is protected by the laws that apply to individuals (see Chapter 3).

If you are self-employed and buy your own health insurance, you are eligible to deduct 100% of the cost of your premium from your federal income tax.

Texas

• · If you are self-employed with no other workers, you are not eligible to buy a small employer group health plan on your own (though you may be able to join another group health plan through a family member). Therefore, the laws that protect employers’ access to group health plans do not apply to you. Your access to health coverage is protected by the laws that apply to individuals.

Louisiana

• If you are self-employed with no other workers, you are not eligible to buy a group health plan on your own (though you may be able to join another group health plan through a family member). Therefore, the laws that protect employers’ access to group health plans do not apply to you. Your access to health insurance is protected by the laws that apply to individuals. (See Chapter 3.)
• If you are self-employed and buy your own health insurance, you may be eligible to deduct 100% of your premium from your federal income tax.

Mississippi

If you are self-employed with no other workers, you are eligible to buy a group health plan on your own. You are guaranteed access to all health insurance sold to small employers.

North Carolina

• If you are self-employed with no other workers, you are treated similarly to other small employers. Insurers cannot refuse to sell you the standard plan or basic plan. However, insurers can refuse to sell you other plans.

• If you are self-employed and buy your own health insurance, you may be eligible to deduct 100% of the cost of your premium from your federal income tax.

Oklahoma

If you are self-employed with no other workers, you are not eligible to buy a group health plan on your own (though you may be able to join another group health plan through a family member). Therefore, the laws that protect employers’ access to group health plans do not apply to you. Your access to health insurance is protected by the laws that apply to individuals.

• · If you are self-employed and buy your own health insurance, you are eligible to deduct 100% of the cost of your premium from your federal income tax.

South Carolina

If you are self-employed with no other workers, you are not eligible to buy a group health plan on your own (though you may be able to join another group health plan through a family member). Therefore, the laws that protect employers’ access to group health plans do not apply to you. Your access to health insurance is protected by the laws that apply to individuals.

• · If you are self-employed and your spouse is considered an employee, then you may be considered a small group for the purpose of purchasing health insurance. (See

above).

• · If you are self-employed and buy your own health insurance, you may be eligible to deduct 100% of the cost of your premium from your federal income tax.

Tennessee

If you are self-employed with no other workers, you are not eligible to buy a group health plan on your own (though you may be able to join another group health plan through a family member). Therefore, the laws that protect employers’ access to group health plans do not apply to you. Your access to health insurance is protected by the laws that apply to individuals.

• · If you are self-employed and buy your own health insurance, you may be eligible to deduct 100% of the cost of your premiums from your federal income tax.

Virginia

• · If you are self-employed with no other workers, you cannot buy a group health plan policy. Therefore, the laws that protect small employers’ access to group health plans do not apply to you. Your access to health insurance is protected by the laws that apply to individuals.
• · If you are self-employed and buy your own health insurance, you may be eligible to deduct 100% of the cost of your premium from your federal income tax.

West Virginia

If you are self-employed with no other workers, you are not eligible to buy a group health plan on your own (though you may be able to join another group health plan through a family member). Therefore, the laws that protect employers’ access to group health plans do not apply to you. Your access to health insurance is protected by the laws that apply to individual.

• · If you are self-employed and buy your own health insurance, you may be eligible to deduct 100% of the cost of your premiums from your federal income tax.

Illinois

If you are self-employed with no other workers, you are not eligible to buy a group health plan on your own (though you may be able to join another group health plan through a family member). Therefore, the laws that protect employers’ access to group health plans do not apply to you. Your access to health insurance is protected by the laws that apply to individuals.

If you are self-employed and buy your own health insurance, you are eligible to deduct 100% of the cost of your premium from your federal income tax.

ILLINOIS COMPREHENSIVE HEALTH INSURANCE PLAN (CHIP)

Illinois has a high-risk pool program, called Illinois Comprehensive Health Insurance Plan (CHIP) that offers insurance for people with health conditions who are unable to buy private health insurance coverage and for people who are HIPAA eligible.  CHIP is also considered a qualified health plan for individuals eligible for the health coverage tax credit (HCTC).  (see Chapter 5) If you lost your health insurance and are receiving benefits from the Trade Adjustment Assistance (TAA) Program then you may be eligible for a federal income tax credit to help pay for new health coverage. This credit is called the Health Coverage Tax Credit (HCTC), and it is equal to 80% of the cost of qualified health coverage, including COBRA, and a specific policy offered through the Illinois Comprehensive Health Insurance Plan (CHIP).  (see Chapter 5)

Iowa

If you are self-employed with no other workers, you are not eligible to buy a group health plan on your own (though you may be able to join another group health plan through a family member). Therefore, the laws that protect employers’ access to group health plan do not apply to you. The laws that apply to individuals protect your access to health insurance.

If you are self-employed and buy your own health insurance, you are eligible to deduct 100% of the cost of your premium from your federal income tax.

Iowa Comprehensive Health Association (HIP-IOWA).The state-run program for people with high health risks (called a high-risk pool). ICHA also sells coverage to those who are HIPAA eligible. See also HIPAA Eligible.

Indiana

If you are self-employed with no other workers, you are not eligible to buy a group health plan on your own (though you may be able to join another group health plan through a family member). Therefore, the laws that protect employers’ access to group health plans do not apply to you. Your access to health insurance is protected by the laws that apply to individuals.

• If you are self-employed and buy your own health insurance, you are eligible to deduct 100% of the cost of your premium from your federal income tax.

Kansas

If you are self-employed with no other workers, you are not eligible to buy a group health plan on your own (though you may be able to join another group health plan through a family member). Therefore, the laws that protect employers’ access to group health plans do not apply to you. Your access to health insurance is protected by the laws that apply to individuals.

• If you are self-employed and buy your own health insurance, you are eligible to deduct 100% of the cost of your premiums from your federal income tax.

KHIA. Kansas Health Insurance Association, the state-run program for people with high health risks (called a high risk pool). KHIA sells individual coverage to those who are federally eligible and to others with serious health conditions who cannot buy affordable coverage from private health insurance co

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PPO Examples of Coverage

An illustration of this would be a CT scan performed in an emergency room is billed as $1700.00, but the allowable amount or CONTRACTED fee for that service already established with the provider is $500; hence you would expect to receive a bill from the hospital for $500.00 that to the insurance company is automatically applied to your annual deductible. The hospital, on the other hand, does not automatically do anything except bill you so you would need to contact the hospital and set up a payment schedule, i.e. $100 a month, and make the payments to them accordingly.

If this emergency room visit was at an out of network hospital then you may be responsible to pay the billed amount of $1700, but your insurance carrier would not consider this OUT OF POCKET or not covered medical benefits, but rather, they would apply this amount to your OUT OF NETWORK DEDUCTIBLE.

Your out of network deductible is usually twice that of your in network deductible. So, if you had a $2500 annual IN NETWORK deductible then you would probably have a $5000 OUT OF NETWORK deductible. The bottom line is, a PPO offers more flexibility in benefits received by a policy holder. You do not need to obtain referrals to visit a specialist although there is often prior authorization required to have a MRI (you cannot just go have an MRI performed for peace of mind, a doctor must order the MRI). A PPO, however, will be more lenient in their definition of prior authorization whereas a HMO may request you to jump through flaming hoops and wait a month before they cover a MRI.

Although a PPO allows you to receive benefits from an out-of-network provider, it is more advantageous to remain within the in-network of providers who have accepted the contracted fees for medical services and usually a PPO will have a robust national network of participating or preferred providers.

We offer many different PPO health insurance plans including plans from Blue Cross Blue Shield, Cigna, Humana, United, Aetna (in many states it is a POS), and many more depending on your state.

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You’ll automatically be enrolled in Medicare if you already collect Social Security or receive benefits from the Railroad Retirement Board when you turn 65, or if you’ve been collecting disability for more than two years. If you’re working and not collecting government pension benefits, you need to sign up three months before your 65th birthday.

First of all, understand clearly that Medicare is not free health care. You’ll have to pay deductibles and co-payments out-of-pocket, and certain services aren’t covered at all.

What you’ll ultimately pay will depend on the type of Medicare plan you choose: whether you’ll have additional health insurance coverage from a former employer; whether you purchase so-called “supplemental coverage”; and how often you make use of the medical services your doctor or hospital offer.

Medicare summary

Listing here everything that Medicare covers and doesn’t cover would take volumes. But following is a brief overview to provide a basic understanding. For more details, visit the Medicare Web site and download the ‘Medicare & You 2008’ handbook

The original plan: Parts A & B

The original plan helps pay for many medical services and supplies provided in hospitals, doctors’ offices and other health care settings. Part A focuses on hospital insurance, while Part B is the program’s medical insurance component. All U.S. citizens and legal residents of the United States who have paid Medicare payroll taxes for 10 years or more are eligible for both Part A and Part B coverage upon reaching age 65.

Part A helps with the cost of inpatient care in hospitals (including inpatient rehabilitation facilities), inpatient stays in a skilled nursing facility (but not custodial or long-term care), inpatient mental health care in a psychiatric hospital (limited to 190 days in a lifetime), as well as hospice care services and home health care services. Medicare Part A will completely cover some of the costs associated with these services and procedures. Others will require out-of-pocket co-payments or the satisfaction of annual deductibles.

Part B helps pay for so-called “medically necessary” services such as doctors’ services, outpatient care and some preventive care services. For a list of covered expenses, see pages 18-25 of the Medicare handbook.

As with Part A, Part B has its own separate annual deductible — $135 for 2008 — as well as its own co-payment and co-insurance costs. Generally speaking, Medicare will pay about 80 percent of the expenses for Part B-covered services and supplies.

“Medicare is comprehensive, it’s guaranteed. But it doesn’t cover all of your costs,” says Paul Precht, director for policy and communications at the Medicare Rights Center.

“You need to be aware of the fact that you will spend money out-of-pocket either for the cost sharing under Medicare or for the cost of supplemental insurance if you don’t have that through an employer or if your income isn’t low enough to qualify for additional assistance through Medicaid. And it’s important to remember that Medicare doesn’t have any annual out-of-pocket limits.”

You usually don’t pay a monthly premium for Part A coverage if you (or your spouse) paid Medicare taxes while working at least 40 calendar quarters. But if you aren’t eligible, you may be able to buy Part A coverage if you meet other conditions.

Those enrolled in Part B have to pay a monthly Part B premium and an annual Part B deductible. Most plan participants will pay the standard monthly premium amount, which is $96.40 in 2008. The monthly premium will be higher for people who earn above certain income thresholds ($82,000 for singles; $164,000 for married folks filing jointly). Financial hardship cases can get this premium covered with governmental help. This premium is deducted from your monthly Social Security payment.

Medicare Part C: Medicare Advantage plans

Formerly known as Medicare+Choice, Medicare Advantage plans are alternatives to the original Medicare plan and are not the same thing as “supplemental insurance” (more about this later). Sometimes called Part C or “MA plans,” these plans are run by private companies but are part of the Medicare program.

Basically, Medicare pays an amount of money for your health care into these private Medicare Advantage plans every month. In return, these plans must provide all of your Part A and Part B benefits, and they must cover at least all of the medically necessary services that the original Medicare plan provides.

MA plans can charge different co-payments, co-insurance and deductibles for their services and generally have set provider networks. This means you likely will be limited to seeing only doctors who belong to the plan, going to certain hospitals for covered services and getting referrals to see specialists. If you use providers who aren’t in the network, you may have to pay the entire cost of the services rendered. However, MA plans can offer extra benefits, such as vision, hearing, dental and health and wellness programs. Most include Medicare prescription drug coverage (usually for an extra cost).

Retirees can choose from five different types of Medicare Advantage plans. Most function like HMOs with specific networks of doctors. Other plans, such as Private Fee-for-Service plans, known as PFFS, allow you to go to any doctor if the doctor agrees to accept the plan’s terms of payment before treating you. Medicare Special Needs plans, or SNPs, serve certain people who are chronically ill, live in institutions such as nursing homes or have other special needs. (The different benefits the various types of Medicare Advantage plans offer are outlined on pages 42-44 of the “Medicare & You 2008” handbook.)

It’s important to call any plan before joining to find out what your services will cost and make sure that a plan will meet your needs. Some plans, for example, will let you use out-of-network providers (sometimes for a higher cost). Also, be sure to check in advance with your doctors or hospital to determine if they accept the plan. To enroll in a Medicare Advantage plan, you can complete a paper application, call the plan by telephone or enroll online. Be aware that there are limitations as to when you can join, switch or drop a Medicare Advantage plan.

Remember, when you join a Medicare Advantage plan, you will have to provide your Medicare number from your Medicare card and the date your Part A and Part B coverage started. You also will generally still pay the monthly Part B premium along with the Medicare Advantage plan’s premium (if it charges one). That includes coverage for Part A and Part B benefits, prescription drug coverage (Part D, if offered) and any other extra benefits.

Medicare Part D: Prescription drug benefit

Medicare offers prescription drug coverage under Part D for everyone with Medicare. But to get Medicare drug coverage, you must take the initiative and join a Medicare drug plan.

Medicare drug plans are run by insurance companies and other private companies Medicare approves. Each plan varies in cost and drugs covered. Even if you don’t take a lot of prescription drugs now, you still should consider joining a Medicare drug plan because if you decide not to join such a plan when you are first eligible, you will pay a late-enrollment penalty if you choose to join later. The penalty is 1 percent of the monthly premium for each month you don’t enroll and is applied to all future monthly premiums.

“Although there will be a number of seniors out there who don’t take any prescription drugs right now and who’ll view paying for prescription drug insurance as kind of a waste, they also need to think about the future,” says Clark Howard, consumer-advice talk-show host and author. “Consequently, you are so much better off holding your nose and picking a plan now rather than having to do so in the future and also having to pay a penalty on top of your regular premiums.”

There are two ways to get Medicare prescription drug coverage:

1. You can join a stand-alone Medicare Prescription Drug plan. These plans, sometimes called PDPs, add drug coverage to the original Medicare plan, to some Medicare PFFS plans, to some Medicare Cost Plans and Medicare Medical Savings Account, or MSA, plans. (The latter two plans are part of the catchall “other Medicare plans” that are not Medicare Advantage plans. Medicare Cost Plans, available only in certain parts of the country, are a variation of the original Medicare plan. An MSA plan combines a high-deductible Medicare Advantage plan and a bank account, much like the consumer-directed health plans that are available in the private sector.)
2. You can join a Medicare Advantage plan (such as an HMO or PPO) or another Medicare health plan that includes prescription drug coverage. Through these you will get all of your Medicare coverage (Part A and Part B), including prescription drugs (Part D). These plans are sometimes called MA-PDs and you will usually pay a separate monthly premium in addition to your Part B premium.

Every year, from Nov. 15 to Dec. 31, you can switch to a different Medicare drug plan if your plan coverage changes or your prescription needs change. When you join or switch to a new Medicare drug plan, your coverage generally will begin on Jan. 1 of the following year.

Medigap policies

The original Medicare plan pays for many, but not all, health care services and supplies. To help pay your out-of-pocket costs, you might want to consider getting a Medigap policy, also called Medicare Supplement Insurance. Note: These plans can’t be used to pay your co-payments or deductibles for Medicare Advantage plans.

You can buy a Medigap plan from a private insurance company, or you might be able to get this supplemental insurance from a former employer (your own or your spouse’s) as a retiree benefit. There are also several government programs that can help you obtain Medigap coverage if you meet certain income requirements or other qualifications.

A Medigap policy is private health insurance that’s designed to supplement the original Medicare plan and help pay some of the health care costs that aren’t covered — such as CO-payments, co-insurance and deductibles. Each Medigap policy only covers one person, so if you and your spouse both want coverage, you each must buy separate Medigap policies.

Each standardized Medigap policy, however, must offer the same basic benefits, no matter which insurance company sells it. Premiums will vary depending on the plan you choose and the company you buy it from (the typical premium is about $150 per month), but usually the only difference among Medigap policies different insurance companies sell is the cost.

The best time to buy a Medigap policy is during your Medigap open-enrollment period. In all states, there is an open-enrollment period that lasts for six months. It begins on the first day of the month in which you are both age 65 or older and enrolled in Part B (some states have additional open enrollment periods). For more information about buying a Medigap policy, call your State Health Insurance Assistance Program.

All Medigap policies must follow federal and state laws that are designed to protect consumers, and every Medigap policy must be clearly identified as “Medicare Supplement Insurance.” Furthermore, Medigap insurance companies can only sell you a “standardized” Medigap policy. There are 12 such policies identified by letters (i.e., Medigap Plans A through L), except in Massachusetts, Minnesota and Wisconsin, where Medigap policies are standardized differently. Also, in some states, you might be able to buy another type of Medigap policy called “Medicare Select,” which is a Medigap policy that requires you to use specific hospitals and, in some cases, specific doctors to get full benefits.

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A health maintenance organization (HMO) is a type of managed care organization (MCO) that provides a form of health care coverage in the United States that is fulfilled through hospitals, doctors, and other providers with which the HMO has a contract. The Health Maintenance Organization Act of 1973 required employers with 25 or more employees to offer federally certified HMO options. Unlike traditional indemnity insurance, an HMO covers only care rendered by those doctors and other professionals who have agreed to treat patients in accordance with the HMO’s guidelines and restrictions in exchange for a steady stream of customers.

I would define an HMO as a health insurance where the insured elects a primary care physician from a list provided to them at the time of enrollment.  That primary care doctor becomes not their focal point as they move around the network of the HMO from seeing specialists to getting referrals for testing.  It is imperative to choose the primary care physician based on prior referrals as this is the only way to be sure that you will get to see the specialists that you want not that the specialists that the insurance companies want.

On the upside, an HMO is about prevention so the everyday use and savings of an HMO is more dramatic than a PPO.  How?  Because, an HMO will cover the diagnostic testing, specialist visits, and routine procedures that the PPO and POS managed care plans will try to apply toward the deductible.  In many cases even with all the downsides of an HMO I believe that the HMO will save you money year after year when compared with a PPO. Of course, in the event of a catastrophic illness or injury, a PPO would be the preferred health insurance plan because you would have more choice in both your network and the tests that you wanted performed.

Cost containment

Although businesses pursued the HMO model for its alleged cost containment benefits, some research indicates that private HMO plans don’t achieve any significant cost savings over non-HMO plans. Although out-of-pocket costs are reduced for consumers, controlling for other factors, the plans don’t affect total expenditures and payments by insurers. A possible reason for this failure is that consumers might increase utilization in response to less cost sharing under HMOs. 

History

The earliest form of HMOs can be seen in a number of prepaid health plans. In 1910, the Western Clinic in Tacoma, Washington offered lumber mill owners and their employees certain medical services from its providers for a premium of $0.50 per member per month. This is considered by some to be the first example of an HMO. However, Ross-Loos Medical Group, established in 1929, is considered to be the first HMO in the United States; it was headquartered in Los Angeles and initially provided services for Los Angeles Department of Water and Power (DWP) and Los Angeles County employees. Approximately 500 DWP employees enrolled at a cost of $1.50 each per month. Within a year, the Los Angeles Fire Department signed up, then the Los Angeles Police Department, then the Southern California Telephone Company, (now at&t) and more.

By 1951, enrollment stood at 35,000 and included teachers, county and city employees. In 1982 through the merger of the Insurance Company of North America (INA) founded in 1792 and Connecticut General (CG) founded in 1865 came together to become CIGNA. Ross-Loos Medical Group, became now known as CIGNA HealthCare. Also in 1929 Dr. Michael Shadid created a health plan in Elk City, Oklahoma in which farmers bought shares for $50 to raise the money to build a hospital. The medical community did not like this arrangement and threatened to suspend Shadid’s licence. The Farmer’s Union took control of the hospital and the health plan in 1934. Also in 1929, Baylor Hospital provided approximately 1,500 teachers with prepaid care. This was the origin of Blue Cross. Around 1939, state medical societies created Blue Shield plans to cover physician services, as Blue Cross covered only hospital services. These prepaid plans burgeoned during the Great Depression as a method for providers to ensure constant and steady revenue.

In 1970, the number of HMOs declined to less than 40. Paul Ellwood, often called the “father” of the HMO, began having discussions with what is today the U.S. Department of Health and Human Services that led to the enactment of the Health Maintenance Organization Act of 1973. This act had three main provisions:

• Grants and loans were provided to plan, start, or expand an HMO
• Certain state-imposed restrictions on HMOs were removed if the HMOs were federally certified
• Employers with 25 or more employees were required to offer federally certified HMO options alongside indemnity upon request

This last provision, called the dual choice provision, was the most important, as it gave HMOs access to the critical employer-based market that had often been blocked in the past. The federal government was slow to issue regulations and certify plans until 1977, when HMOs began to grow rapidly. The dual choice provision expired in 1995.

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In the United States, there are a few main POS health insurance plans that are available for individuals and families. In many states of course there is sometimes an exclusive POS plan for that state as well. In Florida for instance, we have the non-profit health insurance plans from AvMed, and in other states there is a Cigna POS plan depending on where you live. Before we delve into the POS plans too deeply, many of you are here for a simple definition. So, from the great folks who fill out Wikipedia.org, here is their entry:

A point of service plan, or POS plan, is a type of managed care (the definition of managed care plans is basically the category of Network health plans that include PPO’s, HMO’s and POS’s and whatever other acronyms they can think of to define a health plan that has a limited network of providers) health insurance system. It combines characteristics of both the HMO and the PPO. Members of a POS plan do not make a choice about which system to use until the point at which the service is being used.

The POS is based on the basic managed care foundation: lower medical costs in exchange for more limited choice. But POS health insurance does differ from other managed care plans.

When you enroll in a POS plan, you are required to choose a primary care physician to monitor your health care. This primary care physician must be chosen from within the health care network, and becomes your “point of service”.

The primary POS physician may then make referrals outside the network, but then only some compensation will be offered by your health insurance company.
For medical visits within the health care network, paperwork is completed for you. If you choose to go outside the network, it is your responsibility to fill out the forms, send bills in for payment, and keep an accurate account of health care receipts.

This definition is a bit tedious to understand, because to me (and I’ve been selling these health insurance plans for years) a POS plan is a PPO until you start having a large amount of claims. In fact, you will think that you have a PPO until you start racking up some claims then inevitably you will find out that you plan has more in common with an HMO than a PPO. In fact, POS plans in Florida are usually registered with the state as HMO’s (Aetna for example in Florida as well as Avmed).

This doesn’t mean anything bad or that you will get a lesser standard of care at all. In fact, on the plus side, these POS plans tend to be more about prevention than your PPO health insurance plan and you will find that most if not all of you office visit is covered by your copay including the labs and testing and so forth. Whereas with a PPO, you are usually paying for everything except the doctors office visit fees (excluding the copay which of course is yours to cover). This would include, for instance, a typical visit to the dermatologist where a mole is removed. With a PPO, you are paying for the removal of the mole (until you meet your deductible) and your office visit copayment. With a POS plan, you are paying the office visit fee only. (POS plan benefits vary by state and the benefits might be very different in Vermont along with the health insurance plan as well.)

Now the only downside to this glorious plan is that the POS primary physician (which is very simple to change and is not the formal changing process involved as in an HMO physician change, where you usually have to take out an ad in the classifieds announcing your intentions) needs to refer you to out of network physicians and specialists but usually will try to keep you inside the network.

With a POS plan like Aetna, though, the network is really vast and because of the size of the network you will not have a problem getting to see top physicians at all.

At the end of the day, because we live in a health insurance country where managed care plans rule the day (except in the case of Medicare Supplements), POS plans are really quite good and in many cases superior to HMO’s in the event of a serious illness.

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Generally, these plans have a specific deductible and an aggregate deductible. The risk to the employer is actually very specific.

In practice, this means that the employer assumes all claims under that specific deductible while any claims over the specific deductible are picked up by the reinsurer.  In fact, these plans are very much like catastrophic plans the difference being of course that instead of the insured paying for everyday claims they are paid by the employer.

A good example and a common amount for these self insurance plans include a $10,000 deductible, with any claims above this deductible being paid by the secondary insurer.

Deductible and Self Insurance Plans

There is also an aggregate deductible, which is the total amount of expected or maximum claim total in any given year that a company is liable under these self insurance health plans.

To continue our example, a company with 100 employees might make their aggregate deductible $400,000 in a given year.   This means, of course, that all health claims are paid in total up till the $400,000 threshold.

Administration Costs and Self Health Insurance

Another factor in these plans is the administration costs.  By self insuring and handling the administration the companies can really start to see savings.  This is because administration costs can be cut in half when handled in house.

The administration costs of most health insurance plans range from 15-18% of the overall premium.  Some companies even hire a Third Party Administrator to handle this work and secure the stop-loss coverage.

These third party companies will even shop for re-insurers on behalf of the company, or the broker will shop the secondary insurance policy and then recommend a TPA (third party administrator).

• Administration duties consist of
• Claims processing
• Arranging network alliances for discount purposes
• Repricing claims
• Reviewing claims
• Handling referrals and pre-certification of medical procedure
• Handling the pharmacy benefits
• Disease management
• Preparing benefit descriptions and plan documents
• Handling employee benefit and employee questions
• Mailing premium and claims checks to providers
• Tax duties

These Third Party Administrators can be compensated per employee or per claim.

Securing a reinsurer can also be a difficult. At least two years of claim experience is generally required.  There are also a ton of requirements that can make reinsurering a monumental task.  Underwriting is very complex.

As these plans fall under ERISA, they have had many problems in the past due to false promises and underfunding.  Still these plans can be a god send for employers with over 100 employees.

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