For
Employers
1.
What should I consider when choosing a group medical plan?
What will the plan cost?
What types of benefits are included in the plan?
(Deductible/Copays/Drugs)
What physicians are in the network and where are the medical
facilities located?
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2.
What employee benefits do my employees want?
The first step in the process of choosing a new benefit plan
is to determine the types of health benefits that are valued
by the employees the most. This is normally done by personal
knowledge of the employees or a survey used by the benefit consultant.
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Plan Design
3.
What type of medical plan design is best for our company?
This is solved by analyzing many factors that are specific to
the employer:
Do we want our plan to pay for daily health care like doctors
office visits, drugs, routine care, etc.?
How much can the employees afford to pay in premiums, co-pays,
co-insurance,deductibles,etc.?
Where do the employees live and how will they access the benefits?
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4.
Should we be self-funded?
Most firms
that are under 100 employees usually decide to pass the entire
risk to the insurance companies. This is normally an easier
and wiser choice and in this scenario the employer simply pays
their premiums. However, there are exceptions that do exist
for some smaller firms that are under 100 lives.
Once an
employer reaches a certain size and financial strength, the
advantages of being partially self funded do exist. Being self
funded is a risk sharing proposition that can save or cost you
money. Claims costs can fluctuate from year to year and the
success of any self-funded plan will fluctuate accordingly with
claims costs.
Obviously, if claims are low, there is an opportunity to cash
in on your savings. Under a fully insured plan there is no opportunity
to cash in on favorable claims experience. Deciding to go self-
funded requires a knowledgeable Human Resource Dept., planning/projecting,
and the financial strength to support the plan.
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Eligibility
5.
Who is eligible to enroll in the benefit plan?
This is
determined by the guidelines you set when you create/created
your plan. Full time (W2) employees working at least 30 hours
a week are eligible to participate on the plan. Individuals
that are not eligible to participate would be Board of Directors,
family members not working for your company, and independent
contractors doing business with your firm.
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COBRA
6.
When must our company comply with COBRA laws?
Employers
that in the last year have employed more than 20 full time/part-time
employees on 50% or more of the working days, must comply. New
provisions allow for a formula in regard to counting part time
employees (how many hours count to make up one employee). When
the numbers are close it may be best to comply.
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7.
What do we need to comply with COBRA?
Timely notice
to employees is important. Employees must receive notice of
their rights by mail to their home address when they become
covered for benefits as well as termination of employment. Verbal
communication does not constitute notice. Other ways of communicating
this important information are:
Post notice on bulletin boards
Include general notice in employees enrollment packets
Establish internal procedures for COBRA administration is
important. Keep a log of COBRA events-dates, actions,follow-up
timeline, etc. COBRA is complex and many employers have hired
third party administrators to handle COBRA.
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For
Employees
1.
What is a PPO?
PPO stands for Preferred Provider Organization. A PPO is a healthcare
delivery system that contracts with providers of medical care
to offer discounted services to members. Members may seek care
from non-participating providers but generally are penalized
for doing so through additional deductibles or co-payments.
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2. What is an HMO?
HMO stands for Health Maintenance Organization. An HMO is a
group health insurance plan in which members select a primary
care physician (PCP) who will be the initial point of contact
between the member and any specialist the member sees. HMOs
cover a broad range of services, with the emphasis on preventative
care. They typically require very small co-payments and deductibles.
In exchange for the lower costs, however, there is less freedom
of choice for insured individuals using the HMO plan, since
they must obtain care through their PCP, who then determines
whether a specialist is needed.
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3. What is an indemnity plan?
An indemnity plan, often referred to as fee-for-service, reimburses
physicians and hospitals for services performed as well as reimbursing
insured individuals for medical expenses incurred. Such plans
contrast with prepaid plans (like HMOs) that provide services
under previously negotiated terms. The advantages of this plan
are that it allows you to select and see any provider, including
specialists without the need for a referral first. Its flexibility
and freedom, however, come at a higher premium cost.
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4. What is a deductible?
A deductible is a flat amount an insured individual pays before
the insurance company will make any benefit payments under a
policy. Most insurance companies will offer several different
deductible options from which to choose.
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5.
What is a co-payment?
A fixed dollar amount that the insured pays to a provider each
time a medical service is performed.
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6.
What is co-insurance?
Co-insurance is a cost-sharing arrangement in which an insured
member pays a specified proportion of the medical bills. For
example, in an 80/20 plan, the member pays 20% and the insurance
plan pays 80% of each claim for services rendered up to the
out of pocket maximum. After you have reached the maximum out
of pocket, the plan will pay at 100%.
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7.
What is a pre-existing condition and how does it affect medical
insurance coverage?
A pre-existing condition is one that was known or treated for
some specific period of time prior to the person's effective
date of coverage. Most major medical plans have a preexisting
condition clause enabling the carrier to exclude coverage for
a period of time, sometimes as long as 24 months, after the
effective date of coverage. As the definition of a preexisting
condition and the clauses pertaining to them differ between
policies, it is important that individuals be aware of their
policy's provisions.
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8.
What is a provider?
A provider is a hospital, healthcare facility, physician or
other medical professional that provides healthcare services.
You may access network providers by accessing our carrier/forms
section of the web site. Click on the physician finder tab under
the insurance company that insures you. Please note that most
insurance carriers have multiple networks. Refer to your ID
card to determine the network that applies to your plan or contact
your human resource department to verify your network.
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9.
Do I have to receive care from only network providers?
The decision is yours. Each time you need health care, you can
decide whether to see a network or a non-network provider. However,
if you receive care from non-network providers, your benefits
will be paid at the non-network level.
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10.
What are my benefits when I receive care from non-network providers?
When you receive care from non-network providers, you will usually
pay more for your care. Copays usually do not apply for non-network
providers. Your plan will pay covered charges at the non-network
benefit percentage, as stated in your certificate. Your certificate
may also show that a higher deductible and out-of-pocket limit
may apply for non-network charges.
In addition, you will be responsible for all charges made by
non-network providers in excess of the usual, customary and
reasonable rates for the service. Your payment of these excess
charges do not apply toward meeting your deductible or out-of-pocket
limit.
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11.
I went to the doctor's office and asked if they accepted my
insurance carrier. They told me that they did accept my insurance.
I later found out that my claim was paid at the non-network
benefit level. What happened?
This situation
can occur. The problem is communication. The doctor's office
told you that they accept your insurance but did not tell you
that they accept the insurance as a non-network provider. This
situation can be prevented by always asking the doctor office
if they are a participating provider of the specific provider
network that applies to your plan.
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12.
What happens if I have an emergency and I cannot get to a network
provider?
If you have and emergency, GET CARE IMMEDIATELY! Covered charges
for emergency care received 48 hours after the sudden onset
of symptoms are paid at the network benefit level.
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