Obtaining Individual and Family Health Insurance:
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Health Insurance For Your Business
An experienced employee benefits specialist can guide you through the steps to obtain the insurance program of your choice. We offer a comprehensive portfolio of group health, dental, vision, disability, and life insurance benefits. To qualify for group medical coverage, your business, depending on the carrier, needs a minimum of 65% health insurance participation of your full-time (defined as working 30 hours or more per week for 48 weeks or more per year), eligible employees (not independent contractors) with a required employer contribution of 50% or more of employees' health insurance cost. Coverage can be extended to include part-time employees and domestic partners (in some California counties, this may be required). Is my business guaranteed health insurance? Yes, as long as you have at least two employees. The State of California guarantees issuance of health insurance to any business of two or more owners/employees that qualifies according to the standards of the various insurance carriers within the State. In effect, anyone with pre-exisiting medical conditions can obtain health insurance if they are an owner or employee of a legitimate business entity containing two or more persons. A business can operate as a corporation, LLC, partnership, or sole proprietorship and obtain health coverage as long as at least two people are listed as officers or employees of the company.
Are the rates the same regardless of pre-existing conditions? An insurance carrier operating in California must offer a qualifying business all its available plans at initial enrollment and the published rates for these plans may not vary more than 20% within a geographic area. What this means is that regardless of medical issues amongst your employees, you will be offered the same plan selection as a company with no medical issues and will not pay more than 20% over the lowest available premiums. Carriers sometimes guarantee their lowest rates regardless of health issues during limited enrollment periods for businesses with 10 or more enrolling employees. Contact us for more information. Can my employees change health plans? Yes, as long as at the time of initial enrollment, application is made for multiple plans. Anthem Blue Cross, for example, offers groups between 2 and 50 employees the Employee Elect Health Plans portfolio with an offering of 21 PPO plans and 8 HMO plans. Once per year, employees are able to switch to any one of these plan options. Am I locked in for a period of time? No. The policy can be canceled or renewed (by payment) month- to-month. Are you a business owner who already offers employee benefits? It is a great time to consider the new plans. If you are shopping for group coverage for the first time, we offer expert assistance. Perhaps you signed up directly with an insurance carrier and/or do not have adequate representation from an agent? A brief letter from you will appoint us as your agent of choice so that you may receive timely and independent representation at no cost to you. Insurance companies can be specialized in different geographic areas offering competitive rates and solid provider networks in one but not in another area. Some carriers specialize in certain benefits, medical, dental, or vision coverage, or an insurance company might offer dozens of plan options, which ones are right for your business? Our experienced staff is available for informational and enrollment meetings and will assist you in obtaining reliable quotes and important information prior to submitting an application. As our client, you can continue to expect superior customer support and competitive updates. With over 20 years experience as employee benefits specialists, Quote Health Insurance Agency will save you time and money. How do I get a free, no-obligation quote? Medical insurance companies assign rates for businesses with 1-99 employees based on your company's enrolling number of employees, the employee age, home address, number of dependents, and health status. You can obtain instant quotes and apply online here or contact us for a free, no-obligation custom proposal. Please complete the: Employee Census Data. Within 48 hours, you will receive competitive quotes from top carriers for your company's health, dental, vision, disability, and life insurance requirements. For more information, please call (408) 889-3891 to speak to an authorized agent.
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Enrollment Assistance for Seniors What is Medicare? Federal health insurance for people at least 65 years of age or on Medicare disability.
Part B pays for portion of services for physician office visits, emergency room services, surgeon, anesthetist, assistant surgeon, pathology, ambulance, outpatient hospital care and doctor visits in the hospital. Benefits are also provided for chiropractic visits, speech therapy, physical therapy, hospice care, Pap smears, and mammograms. Coverage under Part B require enrollment and a premium payment to Medicare. In 2009, the premium for a senior (making $85,000 or less and couples with income of $170,000 of less) -- is $96.40 Part C also called Medicare Advantage, combines your Part A and Part B options and must cover all medically needed services. The difference is that private insurance companies that are approved by Medicare provide this type of coverage. In most cases, Part C is a lower-cost alternative to the Original Medicare Plan, and providers usually offer extra benefits and include prescription drug coverage (Part D). To join a Medicare Advantage Plan, you must have Medicare Part A and Part B. You will have to pay your monthly Medicare Part B premium to Medicare. In addition, you might have to pay a monthly premium to your Medicare Advantage Plan for the extra benefits that they offer. If you join a Medicare Advantage Plan, a Medigap policy won’t be necessary. To determine availability and provider network coverage in your area, please visit: Medicare Options Compare. Part D provides coverage for prescription drug benefits, called PDP, and is sold through private insurance companies. What is a Medicare (Medigap) Supplement? It is a health insurance policy for seniors sold by private insurance companies to help fill the "gaps” in Federal Medicare Part A and B coverages. These policies provide coverage for health care benefits not covered under the Federal medical insurance program. Prescriptions drugs are generally not covered as this requires separate enrollment in Medicare Part D through a PDP, see more below. How do I shop for a Medicare supplement policy? Insurance companies sell only standardized Medicare policies. These Medicare plans must all have specific benefits so that you can compare them easily. You may choose from amongst 12 different standardized Medicare policies: Plans A through L - see chart here. The benefits in any Medicare policy A through L are the same for any insurance company, though each insurance company decides which Medicare policies it wants to sell and how much it wants to charge. It is important to compare prices amongst companies as there can be a significant difference in price for the same plan benefits. When you buy a Medicare Part A and B supplement policy, you must already be enrolled in Federal Medicare Part A and Part B. You and your spouse must each buy separate Medicare policies as coverage is not provided for spouses.
Some plan options limit their payment to medical providers to 20% of “Medicare-allowed fee schedules” (with Medicare paying its 80%). The difference between the allowed and actual fees, or the excess charge, is not covered by either Medicare or Medicare supplements so look for policies that cover excess charges so as not to leave you vulnerable to out-of-pocket expenses. The most popular Medigap plan is Plan F. For additional information, see the official government website, which allows you to compare Medigap plans in your area. Medicare Hotline (1-800-MEDICARE) offers free Medicare help.
You are able to enroll regardless of health conditions within the first 6 months from when you start Medicare Part B of Medicare. During this open window, you are able to purchase any Medigap plan you choose. Can an insurance company refuse to sell me a Medicare Supplement (Medigap Policy)? Yes. A company can decline you because of poor health unless you fall within the guidelines for the open enrollment period.
How does Medicare Part D work? Medicare Part D is a voluntary program that you may purchase through a PDP (Prescription Drug Plan) available through private insurance companies. Anyone who is entitled to Medicare Part A or enrolled in Part B is eligible. You do not have to be enrolled in Part B to qualify for Part D. To enroll in a Part D plan, you complete an application for the Part D benefit of your choice with a PDP insurance provider. The PDP will enroll you in Part D and inform Medicare that you have enrolled and that you will make claims through their company. Note: Penalty for late enrollment in Medicare Part D: A penalty of 1% per month of the premium is charged if Medicare Part D is purchased after the initial eligibility period (this provision is waived if you continue to receive health insurance coverage through an employer-sponsored health insurance plan). Enrollment for Medicare Part D is offered each year from November 15 through December 31, with coverage effective on January 1. Beneficiaries may use these opportunities to switch PDPs, if they choose. Select a plan with more than 90 of the top 100 prescriptions on its formulary list (to cover future events). The PDP should cover your current prescriptions. You may also consider how brand name prescriptions are classified - Tier 2 or Tier 3. Low monthly premiums may be offset by higher co-payments. Also, avoid plans that require your doctors to get "Prior Authorization" for your prescription drugs. Plans without deductibles are generally preferred. How Can Quote Health Insurance Agency help?A licensed insurance professional can assist you in finding a plan that meets your needs and fits your budget. Our staff will provide you with the necessary forms and brochures and assist you with the application process. At Quote Health Insurance Agency, you will find the largest selection of quality health plans for seniors. We provide on-going customer support and competitive updates. Email us or call (408) 889-3891 for your free quote. |
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Important Facts about Health Savings Account (HSA)
HSAs are tax advantaged medical savings accounts available to taxpayers who are enrolled in a high deductible health plan. The funds contributed to the account are not subject to federal income tax. Unlike a flexible spending account, funds roll over and accumulate year over year if not spent. HSAs are available to individuals, families, and businesses. To be able to set up a HSA, you will need to have a HSA-compatible health insurance plan sold through private insurance companies. You are able to make contributions to a HSA as long as you maintain a HSA-compatible health plan.
Features of a HSA include:
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Facts About COBRA
Most of us have heard the term COBRA when leaving a job, being laid off or when in the process of a divorce. COBRA or the Consolidated Omnibus Budget Reconciliation Act of 1985 was instituted to allow people to continue health care insurance coverage provided by their employers even after they have retired or been terminated. This act, while it can be a boon for those laid-off or divorced, is confusing to many. Here are the salient facts about COBRA :
• You qualify for COBRA if you worked for a company that has more than 20 employees and were covered under a group plan as an employee of the company who has retired or been terminated or are a spouse, ex-spouse or a dependent child of such an employee. • To qualify for COBRA, you must apply for coverage through your employer within 60 days of the terminating event (laid off, reduction in hours, a divorce, a dependent who reaches maturity, a disability). Once COBRA is elected, you will be provided with uninterrupted coverage with the premiums paid by you as of the terminating date. • Cal-Cobra is a California enhancement to the federal COBRA provision and applies to terminating employees of companies with 2 or more employees. To qualify, you apply directly with your employer's insurance company within 60 days of your termination date. Coverage can be continued for up to 18 months. Cal-COBRA and COBRA may be combined for longer coverage. First federal COBRA applies; thereafter, application may be made to the former employer's insurance company for additional coverage of up to 18 months. • Most people find health insurance a more costly affair once they’ve signed up for COBRA and wonder why. This is because your employer pays a part of your premium while you’re a full-time employee. So if you thought your monthly premium was $350 and are presented with a bill for $765 at the end of each month when on COBRA, don’t be surprised or shocked. It only means that your employer has been paying the other $400 for you – the $15 is the 2 percent administrative fee you’re obligated to pay under COBRA. Before you sign up for COBRA, find out from your employer how much premium you have to pay each month. • Don’t wait too long to find your own insurance even if your coverage under your employer’s plan lasts you for a long period of time. Start looking for alternatives at once. It’s going to be a more difficult process, especially if you’ve just lost your main source of income. But consider the alternative - if you suffer a serious medical complaint in the time you’re still under your COBRA coverage, it’s going to be doubly hard and much more expensive to procure your own health insurance.
Also, you may not get coverage for the said complaint and its related diseases in your new plan or you may not be able to qualify at all for private health insurance. If you are in good health, you will most likely be able to obtain similar coverage at significant savings by securing your own health insurance. Instant Quote. • You lose your coverage under COBRA if you’re eligible for Medicare, if you miss out on paying a premium, if your employer stops maintaining a group health plan, or if you obtain coverage that is not subject to any limitations under another health plan. • COBRA coverage is suited for those who are already being treated for some illness under the current plan and for those who have a significant medical history. Your best option is to first obtain COBRA coverage through your employer and once in place, to shop for a more competitive policy. Update:
On February 17, 2009, President Obama signed into law the American Recovery and Reinvestment Act (the "Act"), which includes several important changes to COBRA. The Act provides for a federal subsidy of 65 percent of the COBRA continuation coverage premiums for qualified beneficiaries receiving COBRA continuation coverage due to the covered employee's involuntary termination of employment between September 1, 2008, and December 31, 2009. Click here for Overview.
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Actuary: Actuaries evaluate the likelihood of events and quantify the contingent outcomes in order to minimize losses, both emotional and financial, associated with uncertain undesirable events. Since many events, such as death, cannot be totally avoided, it is helpful to take measures to minimize their financial impact when they occur. Agent: A state-licensed salesperson who represents an insurance company. Association: An organization acting as a third-party insurance administrator on behalf of a business or demographic group. Benefit: Amount payable by the insurance company to a claimant or assignee such as a provider. Brand-name prescription drug: This is a patented drug that is marketed under a specific name by the company that develops and manufactures it. When the patent expires, a generic version of the same drug can generally be procured at significantly lower cost. Broker: A licensed insurance salesperson who provides quotes, plan information, enrollment assistance and on-going customer support and who represents multiple insurance companies, Cafeteria Plan: Also known as Section 125 Plan. Employees of employers with cafeteria plans may obtain such benefits as health insurance, group-term life insurance, and flexible spending account through the plan. Most plans are operated through salary deductions, also called pre-tax deductions. Salary reduction contributions are not actually or constructively received by the participant. Therefore, those contributions are not considered wages for federal income tax purposes. In addition, those sums generally are not subject to FICA and FUTA providing tax savings to both employee and employer. Capitation: Capitation represents a set dollar limit that you or your employer pays to a health maintenance organization (HMO) regardless of utilization. Carrier: The insurance company or HMO offering an insurance plan. Certificate of Insurance: The printed description of the benefits, coverage and exclusion provisions that forms the contract between the insurance carrier and the insured customer. Claim: A demand by an individual (or attending provider) to the insurance company for payment for services obtained from a health care professional. Co-Insurance: This refers to the amount that an individual is required to pay for services after the deductible and/or co-payment has been met. Co-insurance is often specified by a percentage. For example, the insured may pay 20 percent toward the charges for a service with the insurance company covering the balance 80 percent. Usually the amount an insured is required to pay under this provision is limited to a maximum during a calendar, called stop loss. Coordination of Benefits (COB): This applies to group policies and not individual policies. If you are covered by more than one group policy, such as when covered by an employer and also by spouse's employer policy or by membership in certain institutions such as by Medicare, you can combine the two policies for greater or complete coverage but not exceeding the total claim. The plan with the first obligation to pay the claim is called the primary plan, and the other plan is the secondary plan. Usually, the plan covering someone as a participant based on employment is the primary plan, and the plan covering someone as a dependent is the secondary plan. However, a plan is also primary if it doesn't have COB rules. If your eligible dependent children are enrolled in more than one medical plan and another group plan (such as your spouse's plan at work), the birthday rule applies to determine which plan pays benefits first. Under this rule, the plan of the parent whose birthday occurs earliest (month and day) in the year is the primary plan for dependent children. If both parents have the same birthday, the primary plan is the one that has covered a parent longer. If two or more plans cover a person as a dependent child (under 18 years old) of divorced or separated parents (whether or not they were ever married), benefits for the child are determined in this order: The plan of the custodial parent pays first; The plan of the custodial parent's spouse pays second; and The plan of the non-custodial parent pays third. If the divorce settlement specifies otherwise, a copy of the court order is required, and the plans will follow the court order. There are other COB rules, and this description is intended only as a summary of the main rules. Co-Payment: Co-payment is a predetermined flat fee that an individual pays for health care services usually at the time of visit. Depending on the policy and services provided it may or may not cover charges for the entire visit. COBRA: Federal legislation that allows you and your family to purchase health insurance coverage under your former employer's group plan for a specific number of months. Credit for Prior Coverage: This provision allows individuals to receive credit for pre-existing condition coverage when changing health insurance plans thus securing uninterrupted coverage for pre-existing conditons for individuals who had recent prior coverage with another insurance company. Proof of prior coverage is required. HMOs usually have no waiting periods for coverage so this provision would not be necessary. Deductible: The annual amount an individual must pay for health care expenses before insurance covers the cost for specific benefits. Dependents: Spouse and/or unmarried children (whether natural, adopted or step) of an insured. Unless dependent children are enrolled full-time in college, in which case they are eligible to continue coverage under a parent's policy to age 23, children are covered until age 19 . Effective Date: The date your insurance coverage begins. You are not covered for benefits until the policy's effective date. Exclusions: Medical services that are not covered by an insurance policy. Explanation of Benefits: The insurance company's written explanation to a claimant explaining what has been paid by the insurance company and the amount for which the insured is responsible. Flexible Spending Account(FSA) is one of a number of tax-advantaged financial accounts that can be set up through a cafeteria plan of an employer. An FSA allows an employee to set aside a portion of his or her earnings on a pre-tax basis to pay for qualified expenses as established in the cafeteria plan, most commonly for medical expenses but often for dependent care or other expenses. Money deducted from an employee's pay into an FSA is not subject to payroll taxes, resulting in a substantial payroll tax savings to employers as well as tax savings to employees. The amount to be contributed must be decided by the participant at the beginning of the year and any unused allocated funds are forfeited. Formulary is a list of prescription drugs covered by a particular drug benefit plan. Formularies are based on evaluations of efficacy, safety, and cost-effectiveness of drugs. Patients pay varying co-pays for drugs that are on formulary. For drugs that are not on formulary, patients must pay a larger percentage of the cost of the drug, sometimes 100%. Formularies vary between drug plans and differ in the breadth of drugs covered and costs of co-pay and premiums. Most formularies cover at least one drug in each drug class, and encourage generic substitution (also known as a preferred drug list). Generic Drug: Generic drugs are copies of brand-name drugs with expired patents that have exactly the same dosage, intended use, effects, side effects, route of administration, risks, safety, and strength as the original drug. Generic drugs are only cheaper because the manufacturers have not had the expenses of developing and marketing a new drug. Group Insurance: Coverage through an employer or other entity that covers all individuals in the group. Coverage is guaranteed for qualifying businesses with two or more employees. Health maintenance organization (HMO) is a type of managed care organization that provides a form of health care coverage that is fulfilled through hospitals, doctors, and other providers with which the HMO has a contract. 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. Most HMOs require members to select a primary care physician , a doctor who acts as a "gatekeeper" to direct access to medical services. Absent a medical emergency, patients need a referral from the PCP in order to see a specialist or other doctor, and the gatekeeper cannot authorize that referral unless the HMO guidelines deem it necessary. The appeal is the lack of additional charges to the insured such as co-insurances and deductibles as generally only a flat fee is required at the time of service. Also, HMOs usually have no pre-existing condition exclusions and often offer unlimited lifetime benefits to members. HIPAA: Or "The Health Insurance Portability and Accountability Act of 1996" allows persons to qualify immediately for comparable health insurance coverage when changing employment and also applies to individual policies requiring pre-existing condition credits when insured has maintained recent prior coverage. It also created the authority to mandate the use of standards for the electronic exchange of health care data and specifies what medical and administrative code sets should be used within those standards, and it requires the use of national identification systems for health care patients, providers, payers (or plans), and employers (or sponsors) and specifies the types of measures required to protect the security and privacy of personally identifiable health care. Health Savings account (HSA): is a tax-advantaged medical savings account available to taxpayers who are enrolled in a High Deductible Health Plan. The funds contributed to the account are not subject to federal income tax at the time of deposit. Unlike a flexible spending account, funds roll over and accumulate year over year if not spent. HSAs are owned by the individual, which differentiates them from the company-owned health reimbursement arrangement. Funds may be used to pay for qualified medical expenses at any time without federal tax liability. Withdrawals for non-medical expenses are treated very similarly to those in an IRA in that they may provide tax advantages if taken after retirement age, and they incur penalties if taken earlier. These accounts are a component of consumer driven health care encouraging consumers to shop for less expensive health care services by being a direct participant in the cost. In-Network: Providers or health care facilities with which the insurance company has negotiated discounts. Insured individuals usually pay less when using an in-network provider because those networks provide services at lower cost to the insurance companies with which they are contracted. It eliminates Usual, Customary and Reasonable charge limitations as an insured will only pay the percentage amount of the pre-negotiated fee. Indemnity Health Plan: Indemnity health insurance plans are also called "fee-for-service." These are the types of plans that primarily existed before the rise of HMOs, IPAs, and PPOs. With indemnity plans, the individual pays a pre-determined percentage of the cost of health care services, and the insurance company pays the other percentage. For example, an individual might pay 20 percent for services and the insurance company pays 80 percent of Usual, Customary and Reasonable charges (UCR). The fees for services are defined by the providers and vary from physician to physician. Sometimes the UCR limitation of insurance companies does not cover the actual charges and the insured is responsible for the excess charges. Indemnity health plans offer individuals the freedom to choose their health care professionals. Independent Practice Associations: IPAs are similar to HMOs, except that individuals receive care in a physician's own office, rather than in an HMO facility. It is a group of individual health providers that has created its own HMO. Individual Health Insurance: Health insurance coverage for an individual or family (vs. employer group insurance) subject to approval based on a medical health questionnaire completed at the time of application. Lifetime Maximum Benefit (or Maximum Lifetime Benefit): the maximum amount a health plan will pay in benefits to an insured individual during that individual's lifetime. For PPO's it can range from $500,000 to 6,000,000. HMOs usually provide unlimited lifetime benefits Limitations: a limit on the amount of benefits paid out for a particular covered expense, as disclosed on the Certificate of Insurance. Long-Term Care Policy: Long-term care refers to the many services beyond medical care and nursing care used by people who have disabilities or chronic (long-lasting) illnesses. Long-term care insurance helps you pay for these services, which can be very expensive. Coverage usually includes: help in your home with daily activities like bathing, dressing, eating and cleaning; community programs, such as adult day care; assisted living services that are provided in a special residential setting other than your own home. These services may include meals, health monitoring, and help with daily activities. Long term care policies cover specified services for a specified period of time and for a specified benefit amount. Long-term Disability Insurance: Pays an insured a percentage of their insured monthly earnings (usually about 50- 60% of pre-disability income) if they become disabled. "Own Occupation" definition of disability is preferred as it pays benefits if an individual is unable to perform the material and substantial duties of his own occupation due to sickness or injury…even if able to do some other kind of work. Managed Care: A medical delivery system that manages the quality and cost of medical services that individuals receive. Most managed care systems offer HMOs and PPOs that individuals are encouraged to use for their health care services. Some managed care plans try to improve health quality, by emphasizing prevention of disease. MedIcare (gap) Insurance Policies: Medicare policies are offered by private insurance companies and are designed to pay for medical expenses not covered by Medicare. Multiple Employer Trust (MET): A trust consisting of multiple small employers in the same industry, formed for the purpose of purchasing group health insurance or establishing a self-funded plan at a lower cost than might be available to each of the employers individually. Network: A group of doctors, hospitals and other health care providers contracted to provide services to insurance companies customers for less than their usual fees. Provider networks can cover a large geographic market or a wide range of health care services. Insured individuals typically pay less by using a network provider. Open-ended HMOs: HMOs which allow enrolled individuals to use out-of-plan providers and still receive partial or full coverage and payment for the professional's services. Out-of-Network (Out-of-Plan): This phrase usually refers to physicians, hospitals and other health care providers who are considered non-participants in an insurance plan. Depending on an individual's health insurance plan, expenses incurred by services provided by out-of-plan health professionals may or may not be covered, and if covered, only in part and usually subject to pre-determined fee schedules. Out-Of-Pocket Maximum: The amount of money that an individual must pay out of their own pocket before an insurance company or (self-insured employer) will pay 100 percent for an individual's health care expenses for the balance of the calendar year up to the lifetime maximium. It is the combined annual total of the deductible and the co-insurance amount an insured is required to pay. Outpatient: An individual who receives health care services on an outpatient basis, meaning they do not stay overnight in a hospital or in an inpatient facility. Many insurance companies have identified a list of tests and procedures (including surgery) that will not be covered (paid for) unless they are performed on an outpatient basis. The term outpatient is also used synonymously with ambulatory to describe health care facilities where procedures are performed. Pre-Admission Certification: Also called pre-certification review, or pre-admission review. It is an approval by a case manager or insurance company representative (usually a nurse) for a person to be admitted to a hospital or in-patient facility granted prior to the admittance. Pre-admission certification often must be obtained by the individual before being able to obtain insurance benefits. The goal of pre-admission certification is to ensure that individuals are not exposed to inappropriate or unneccessary health care services. Pre-Admission Review: A review of an individual's health care status or condition, prior to an individual being admitted to an inpatient health care facility, such as a hospital. Pre-admission reviews are often conducted by case managers or insurance company representatives (usually nurses) in cooperation with the individual, his or her physician or health care provider, and hospitals. Pre-existing Conditions: A medical condition that is manifest prior to the individual obtaining a health insurance policy. Coverage for pre-exisiting conditions are often excluded for a period of time. Most insurance carriers will exclude coverage for anything treated in the 6 month prior to the policy's effective date for a period of 6 months following this effective date. If the insured has qualifying prior health coverage, this exclusion for coverage of a pre-existing conditions is fully or partially waived. HMOs usually don't have this exclusion and upon approval all conditions are covered. Preadmission Testing: Medical tests that are completed for an individual prior to being admitted to a hospital or inpatient health care facility. Preferred Provider Organizations (PPOs): is a managed care organization of medical doctors, hospitals and other health care providers who have contracted with an insurer or a third-party administrator to provide health care at reduced rates to the insurer's or administrator's clients. The idea of a preferred provider organization is that the providers will provide the insured members of the group a substantial discount below their regularly-charged rates. PPOs have grown in popularity and are now the leading type of health plans. They differ from HMOs in that an individual can self-refer to providers within and even outside the network. Primary Care Provider (PCP): A health care professional (internist, family doctor, etc.) who is responsible for monitoring an individual's overall health care needs. Typically, a PCP serves as a "gatekeeper" for an individual's medical care referring the individual to more specialized physicians as needed and as provided for by the insurance plan. Provider: Provider is a term used for health professionals who provide health care services. Sometimes, the term refers only to physicians. Often, however, the term also refers to other health care professionals such as hospitals, nurse practitioners, chiropractors, physical therapists, and others offering specialized health care services. Reasonable and Customary Fees: The average fee charged by a particular type of health care practitioner within a geographic area. The term is often used by medical plans as the amount they will approve for a specific tests or procedures. If the fees are higher than the approved amount, the individual receiving the service is responsible for the difference. This feature is more common with indemnity plans which have been replaced in large by PPOs and HMOs. Rider: A modification made to a Certificate of Insurance regarding the clauses and provisions of a policy which add or exclude coverage beyond the normal limits of a policy. Risk: The chance of loss, the degree of probability of loss or the amount of possible loss to the insuring company. For an individual, risk represents such probabilities as the likelihood of surgical complications, medications' side effects, exposure to infection, or the chance of suffering a medical problem because of a lifestyle or other choice. . Second Opinion: It is a medical opinion provided by a second physician or medical expert when a physician provides a diagnosis or recommends surgery to an individual. Individuals are encouraged to obtain second opinions whenever a physician recommends surgery or presents an individual with a serious medical diagnosis. Second Surgical Opinion: These are now standard benefits in many health insurance plans. It is an opinion provided by a second physician when a physician recommends surgery to an individual. Short-Term Disability: Insurance to protect an employed persons income in the event of an injury or illness that keeps a person from working for a short time, usually up to a year. The definition of short-term disability (and the time period over which coverage extends) differs among insurance companies and employers. Short-term disability insurance coverage is designed to protect an individual's full or partial wages during a time of injury or illness (which is not work-related) that might prohibit the individual from working. This type of insurance differs from worker's compensation in that the injury or illness did not occur during activity at the work place. Short-Term Medical Insurance: Temporary coverage for an individual for a short period of time, usually from 30 days to six months. It requires only a brief enrollment form and coverage is simpler and easier to obtain than for a regular (long-term) health policy. It is ideal for interim coverage such as when waiting for approval for individual coverage or when in between jobs. Pre-exisiting conditions are usually not covered. State Mandated Benefits: Health care benefits mandated by the State requiring health insurance companies to include specific benefits. Many preventative benefits such as mammograms, PAPs, and prenatal care are mandated. Stop-loss: When subject to coinsurance, this is the maximum dollar amount an insured is required to pay for his or her portion of the co-insurance during a calendar year. Travel Health Insurance Most health insurance plans cover emergency care during international travel. If you would like to supplement this coverage, you may want to separately purchase travel health insurance: Travel Health Insurance Quotes Underwriter: The insurance company's department that researches and assumes responsibility for the risk and issuance of insurance policies. Usual, Customary and Reasonable (UCR) or Covered Expenses: An amount customarily charged for or covered for similar services and supplies which are medically necessary, recommended by a doctor, or required for treatment. Also called Reasonable and Customary charges. Waiting Period: A period of time when specified benefits are not covered. For example, with dental insurance, services for major treatments are oftentimes not covered for the first policy year. Workers compensation or workers' comp is a form of insurance that provides compensation medical care for employees who are injured in the course of employment, in exchange for mandatory relinquishment of the employee's right to sue his or her employer for the tort of negligence. Private health insurance will not pay benefits for injuries and illnesses sustained at the work place when covered by worker's comp policy. Please note that this help file is intended only as a brief guide to assist California health insurance consumers in gaining greater comprehension of their choices and is provided with the understanding that Quote Health Insurance Agency is not providing legal or tax advice. |
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